Category Archives: Neurology

Introduction

This database is intended to facilitate the ability of veterinary students and practitioners to make an accurate anatomic diagnosis of disorders of the nervous system in domestic animals.

The video clips on this web site are a component of the fifth edition of de Lahunta's Veterinary Neuroanatomy and Clinical Neurology by doctors Alexander de Lahunta, Eric Glass and Marc Kent and published by Elsevier in 2020. These video clips are organized by the chapters in this textbook where the case descriptions of the patients observed in the video clips can be found. These video clips have been selected from the collection compiled by the authors during their collective 80 years of experience. Where appropriate for each video clip, the anatomic diagnosis and clinical diagnosis are available on this web site. The basis for the anatomic diagnosis and the discussion of the differential diagnosis are found in the textbook. For the fifth edition of this textbook, the title has been changed to reflect the enormity of the contributions made by Dr. de Lahunta in creating the first and second editions.

The College of Veterinary Medicine of Cornell University, acknowledges Dr. de Lahunta's vast contributions to the field of Veterinary Neurology. His work has not only contributed significantly to the global knowledge of Veterinary Anatomy and Clinical Neurology, but also to many other aspects of veterinary medicine, enhancing the professional lives of veterinarians all over the world.

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Video Resources for Veterinary Neuroanatomy and Clinical Neurology

To find out if the brain development of a newborn baby is normal, doctors usually look at among other things a small reflex action, triggered by exerting a tiny amount of pressure on the palm of the hand or the sole of the foot. This little movement in the first months of life provides invaluable information.

Llus Barraquer Roviralta considered the father of neurology in Spain first utilized this technique over a century ago at Sant Pau Hospital in Barcelona. A full 140 years of scientific advances (and three generations of Barraquers) have now passed in the neurology clinics of Sant Pau. Today, specialized services in this area of medicine have taken giant leaps, thanks to the development of imaging technology.

This is the decade of neurology, proclaims Albert Lle, the current director of the department that Barraquer created. The 50-year-old neurologist recently received a lot of media attention after his team successfully treated the 92-year-old former premier of Catalonia, Jordi Pujol, after he suffered a stroke. Pujol was released from hospital last weekend.

This interview has been translated and edited for clarity and brevity.

Question. How has the field of neurology changed in 140 years?

Answer. Neurological disorders are becoming more frequent. Many of these are age-related diseases this is to be expected, given that people are living longer. Its projected that the prevalence of degenerative diseases could triple within the next 30 years.

Q. How has the prognosis of these diseases evolved?

A. Thirty years ago, there were very few diseases that had effective treatment. In most cases, the causes and mechanisms were not well understood. For strokes, there were only antiaggregants, such as aspirin. Practically nothing was known about degenerative diseases. As for neuromuscular diseases, only cortisone or very broad-acting immunosuppressants were available. What has happened in recent years is that more knowledge about the causes has resulted in more effective treatments.

Q. It used to be said that neurologists know all about the diseases, but they cant cure any of them

A. This belief is totally obsolete. There are effective treatments for cerebral vascular diseases, for stopping blood clots from growing or causing problems there are very effective treatments for migraines, theres gene therapy treatment being carried out for spinal muscular atrophy. Perhaps the most difficult diseases to treat are Alzheimers and Parkinsons.

Q. These are good times for neurology, then?

A. We are in a fantastic era, because of the therapeutic tools we have access to. But the rise of neurological diseases is also, in turn, a time bomb, because it can squeeze health services. We have aging populations, a greater prevalence of chronic diseases all of this comes at a very high cost, the treatments arent cheap. This is why its very important to have adequate plans for Alzheimers, for example, or for other neurodegenerative diseases, to prioritize where were going to put the money do we put it into long-term care homes or do we put it in research?

Q. Last week, former Catalan premier Jordi Pujol was proof that strokes can be reversible, even at an advanced age.

A. Today, more and more work is being done on biological age rather than on chronological age. That is, you can be 60 years old, but have the brain of an 80-year-old, because youve had an unhealthy lifestyle.

The rise of neurological diseases is a time bomb, because it can squeeze health services

Q. Mar Castellanos, the head of neurology at A Corua Hospital, said in an interview with EL PAS that strokes dont just take place among the elderly more and more often, they are affecting the working age population. Why is this happening?

A. A stroke is highly influenced by lifestyle: smoking, diabetes, high cholesterol, a sedentary lifestyle, high stress levels age is not the only factor.

Q. Speaking of lifestyle even though were living longer, are we living worse? Are we harming our brain with our habits?

A. I think there is still a lack of awareness regarding the prevention and early detection of neurological diseases. In the case of a stroke, for example, there are people who still think that its not necessary to go to the emergency room, that you can wait and see if it goes away. We see this every day. And why is this happening? Because cardiovascular or cancer prevention campaigns began in the 1970s, but in neurology, they started much later weve been repeating this message for less time. In the case of a stroke, time is brain: the longer it takes to get to the hospital, the more brain damage there will be. Neurological diseases have been largely neglected from the point of view of awareness campaigns and funding.

Q. Theres a kind of knowledge black hole when it comes to neurodegenerative diseases, which still have no treatment. Why?

A. Alzheimers, Parkinsons these are very difficult diseases to study and treat. Sometimes, many years may pass before a person notices the first symptoms. By the time they begin to notice and seek help, there is already significant brain damage. When someone has a tumor, oncologists do a biopsy of the tissue, analyze it and look for viable treatment options. But you cant do a biopsy in the brain: we depend on imaging techniques, which dont have microscopic resolution. We arent able to examine these diseases in detail in the early stages not knowing whats happening during these critical years makes it difficult to find treatments.

In Alzheimers, there are more than 50 genes involved its very difficult to know what the sequence of events is. Even so, I would say that much progress has been made. And its also very clear that the greatest advances have been made in the degenerative diseases that have received the most funding, like Alzheimers and MS. The common thread of all chronic diseases except for strokes is to understand the immune system in our brain, about which very little is known. This will be essential research over the coming decades.

Q. How can the healthcare system remain sustainable?

A. Its necessary to carry out a cost-effectiveness analysis. If we manage to reduce or postpone the onset of Alzheimers for five years with effective treatments, we can reduce the number of total cases and, most importantly, improve peoples quality of life. This has a very high cost, but maybe it will buy patients a few extra years of life outside of long-term care.

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Time is brain: The longer you take to go to the hospital after a stroke, the worse the damage - EL PAS USA

The NFL Players Association's investigation into why Tua Tagovailoa was allowed to return in Week 3 after appearing to suffer a head injury took a drastic turn Saturday afternoon.

The union fired the independent neurotrauma doctor who was "involved" in the situation at the game between the Miami Dolphins and the Buffalo Bills, according to Pro Football Talk. Tagovailoa suffered what the team announced was a "head injury" after being knocked to the ground, standing up and stumbling before leaving the game. The hit appeared to end Tagovailoa's day, but he ended up returning to the game for the second half to lead the Dolphins to a 21-19 win.

That decision raised a lot of eyebrows and prompted the NFLPA to officially open up an investigation into the incident.

Tagovailoa was reportedly checked for a concussion all week and passed all the necessary tests leading to the Dolphins' Week 4 game against the Cincinnati Bengals just four days later. Tagovailoa suffered another scary-looking injury Thursday night, though, after being slammed to the ground before he was stretchered off the field and taken to a hospital. He was discharged that night and flew home with the team.

The investigation is still ongoing, but the independent doctor and the Dolphins team physician were reportedly interviewed on Friday as part of the investigation, according to NFL Network's Tom Pelissero. The NFLPA reportedly found that the doctor made "several mistakes" during the game.

Tua Tagovailoa is at the center of a major NLFPA investigation. (Photo by Megan Briggs/Getty Images)

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NFLPA reportedly fires independent neurologist who was at Week 3 game where Tua Tagovailoa returned after head injury - Yahoo Sports

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Nathan Carberry, M.D., has joined the University of Miami Health System's Neuromuscular Division as an assistant professor of clinical neurology.

Dr. Carberry studied bioengineering at the University of Pennsylvania and earned his medical degree at New York Medical College, with AOA honors society distinction. He completed his medical internship, neurology residency, and fellowship in clinical neurophysiology (EMG/Neuromuscular Medicine) at Columbia University College of Physicians and Surgeons. Dr. Carberry's clinical and research interests are electrodiagnostic medicine, motor neuron disease, and neuropathy.

Name:Nathan Carberry, M.D.

Title:Assistant Professor of Clinical Neurology, Neuromuscular Division

Clinical Specialties:Neuromuscular medicine (motor neuron disease and neuropathy) and general neurology

Research Interests: Electrodiagnostic medicine, motor neuron disease, and neuropathy

Education:

Certifications:

Languages Spoken:English

Practice Locations:

1150 NW 14th Street- Suite 609

Appointments: 305-243-3100

See the article here:
Dr. Nathan Carberry Joins the Department of Neurology - InventUM | University of Miami Miller School of Medicine

Background

Medical comorbidities and neurological manifestations are commonly associated with COVID-19, though specific relationships remain unclear.

The aim of this study is to investigate the relationship between medical comorbidities and neurological manifestations in patients with COVID-19.

We reviewed medical comorbidities and COVID-19-related central nervous system (CNS) and peripheral nervous system (PNS) manifestations in 484 consecutive patients with COVID-19.

Neurological manifestations were seen in 345 (71%) of 484 COVID-19 patients. CNS manifestations included headaches (22%), altered mental status (19%), dizziness (8%), gait imbalance (5%), strokes (four patients, <1%), and seizures (two patients, <1%). PNS manifestations included myalgia (31%), hypogeusia (8%), hyposmia (6%), critical illness myopathy (nine patients, 2%), visual disturbance (six patients, 1%), rhabdomyolysis (four patients, <1%), and nerve pain (one patient, <1%). There were 153 (32%) patients with CNS manifestations, 98 (20%) patients with PNS manifestations, and 94 (19%) patients with combined CNS and PNS manifestations. Comorbidities such as cardiac disease (22%), dementia (17%), hypertension (16%), and chronic obstructive pulmonary disease (COPD; 13%) were significantly associated with CNS manifestations. No comorbidities were associated with PNS manifestations.

Neurological manifestations were common in our sample of 484 COVID-19 patients, with headache and altered mental status being the most common CNS manifestations and myalgia being the most common PNS manifestation. Cardiac disease, dementia, hypertension, and COPD were more common in patients with CNS manifestations. Providers should be vigilant about the possible emergence of CNS manifestations in COVID-19 patients with these comorbid conditions.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes, coronavirus disease 2019 (COVID-19), can present with a range of manifestations such as fever, cough, shortness of breath, fatigue, nausea, vomiting, and diarrhea. Multiple medical comorbidities have been linked to severe disease and mortality, including cardiovascular diseases, cancer, chronic kidney disease, chronic lung diseases, dementia, diabetes mellitus, and obesity. Research has also documented a diverse constellation of central nervous system (CNS) and peripheral nervous system (PNS) manifestations including altered mental status, dizziness, gait imbalance, headache, hyposmia, hypogeusia, seizure, and stroke [1-3]. These neurological signs and symptoms have been reported in more than half of hospitalized patients with COVID-19 and are associated with an increased risk of mortality [1,4,5]. Interestingly, involvement of the CNS and PNS is independent of the severity of the respiratory disease, presenting a challenge for treating neurologists.

While medical comorbidities and neurological manifestations have well-documented associations with COVID-19, there remains much to learn about the specific nature of these relationships. As such, it is important to understand which medical comorbidities increase the risk of neurological manifestations in patients with COVID-19 and whether specific comorbidities increase the risk for CNS or PNS manifestations. This study investigates the association between medical comorbidities and CNS and PNS manifestations in patients with COVID-19 to further elucidate the nature of these relationships.

Data were collected through a clinical chart review of 484 consecutive patients with SARS-CoV-2 infection seen in outpatient clinics and the hospital between February 20, 2020, and July 4, 2020, at EvergreenHealth Medical Center in Kirkland, WA, the first hospital with reported cases in the United States. All patients had SARS-CoV-2 infection confirmed by polymerase chain reaction testing of a nasopharyngeal sample. The study was approved by Western Institutional Review Board, which is our institutional review board and ethics committee.

Data included demographic characteristics, medical history, and presenting manifestations. Only new-onset neurological manifestations were analyzed. Chart notes were independently reviewed by a neurologist and neuropsychologist, and data were cross-referenced for accuracy. Presenting signs and symptoms were reported by patients, family members, care partners, nursing staff, emergency responders, and physicians.

Descriptive statistics (mean [M], standard deviation [SD], percentage) were computed for relevant variables. Categorical variables were presented as absolute values along with percentages and compared using the Pearson 2 test. All tests were two-sided, with a p-value less than 0.05 considered statistically significant. All 345 patients displaying neurological signs and symptoms were divided into three groups: (1) patients with only CNS manifestations, (2) patients with only PNS manifestations, and (3) patients with both CNS and PNS manifestations. Chi-square tests were carried out using Excel functions and null hypothesis. The critical 2 value for comparison of three groups was calculated using two degrees of freedom with a p-value of 0.05. The problem 2 was calculated for each comorbid condition by summing the values calculated using the formula (O-E)2/E for each CNS, PNS, and CNS/PNS groups, where O = observed frequency of CNS, PNS, or CNS/PNS group, and E = expected frequency of the comorbid condition of each of the CNS, PNS, or CNS/PNS group. If the problem 2 value for the comorbid condition is greater than the calculated 2 value of the comorbid condition group, the null hypothesis was rejected, indicating that the difference between observed frequencies and expected frequencies is large enough to be considered statistically significant.

Clinical characteristics and preadmission comorbidities of patients with nervous system involvement are presented in Table 1. Neurological manifestations were seen in 345 (71%) of 484 COVID-19 patients. The average age of patients with neurological manifestations was 59 years (M = 58.8, SD = 20.6). The majority were Caucasian/white (79.4%), with slightly more females (51%). In our sample of 484 COVID-19 patients, there were 153 (32%) patients with CNS manifestations, 98 (20%) patients with PNS manifestations, and 94 (19%) patients with combined CNS and PNS manifestations. CNS manifestations included headaches (107 patients, 22%), altered mental status (92 patients, 19%), dizziness (40 patients, 8%), gait imbalance (23 patients, 5%), strokes (four patients, <1%), and seizures (two patients, <1%). PNS manifestations included myalgia (151 patients, 31%), hypogeusia (38 patients, 8%), hyposmia (27 patients, 6%), critical illness myopathy (nine patients, 2%), visual disturbance (six patients, 1%), rhabdomyolysis (four patients, <1%), and nerve pain (one patient, <1%). The most common comorbid condition associated with CNS manifestations was cardiac disease. Comorbidities such as cardiac disease (108 patients, 22%), dementia (83 patients, 17%), hypertension (76 patients, 16%), and COPD (61 patients, 13%) were significantly associated with CNS manifestations. No comorbidities were associated with PNS manifestations.

In our review of 484 patients with COVID-19 presenting to outpatient clinics and the emergency department, 345 (71%) had neurological manifestations. Of the 345 patients with neurological manifestations, 153 (32%) had CNS manifestations, 98 (20%) had PNS manifestations, and 94 (19%) had both CNS and PNS manifestations. Several comorbid conditions were associated with CNS manifestations (cardiac disease, dementia, hypertension, and COPD), though no comorbidities were associated with PNS manifestations. Our results are largely consistent with those of prior studies and suggest that neurological signs and symptoms are common presenting features of COVID-19 [6-8].

The pathophysiology of neurological manifestations in COVID-19 is mechanistically diverse and includes direct neuroinvasion, immune dysregulation and systemic inflammation, hypoxic-ischemic processes, endothelial damage and microvascular injury, maladaptation of the angiotensin-converting enzyme (ACE2) pathway, and the unique psychosocial impacts of this infection and related pandemic [5,9]. Several studies have reported the presence of SARS-CoV-2 in the cerebral spinal fluid and postmortem brain tissue of COVID-19 patients with encephalitis [10,11]. Early reports suggested that SARS-CoV-2 may gain access through nasal epithelial cells, infiltrating the bloodstream and lymph to reach other tissues [12-15]. However, while the neurotrophic properties of the virus represent one potential route to neurological dysfunction, research indicates that neurological complications are more commonly the result of severe systemic inflammation rather than direct neuroinvasion [16]. Immune-mediated mechanisms influence function of macrophages, microglia, and astrocytes, and are closely related to the development of a systemic inflammatory response. The neurovirulence of COVID-19 correlates with its ability to induce proinflammatory cytokine signals from astrocytes and microglia. SARS-CoV-2 can promote a proinflammatory state by activating glial cells [17]. Virus proliferation in lung tissue may precipitate cerebral hypoxia and anaerobic metabolism, leading to manifestations such as altered mental status, dizziness, gait imbalance, and stroke. This is particularly true for vulnerable individuals such as those with cardiac disease, hypertension, dementia, and COPD [4]. Strokes have been documented extensively in COVID-19 patients, though less than 1% of our patients experienced stroke.

Early research demonstrated that SARS-CoV-2 attaches to ACE2 receptors in the capillary endothelium [18,19], which, in turn, may cause abnormally elevated blood pressure, acute cerebral infarction or hemorrhage, and/or cerebral sinus venous thrombosis. ACE2 is expressed in various organs including the brain, lung, and blood vessels, and plays a role in regulation of a potent vasoactive peptide hormone, angiotensin II. ACE2 also acts as anti-inflammatory, and inhibition of ACE2 results in overactivation of inflammatory pathways. Additionally, psychosocial stressors caused by COVID-19 may also contribute to autonomic dysfunction. Autonomic dysfunction is characterized by elevated sympathetic activity and withdrawal of parasympathetic activity and is a common pathophysiological condition in patients with heart disease, hypertension, and diabetes [20].

Hyposmia is a well-known neurological manifestation of COVID-19. However, hyposmia occurred in only 27 (6%) of our patients, likely due to the older age and high rate of dementia in our sample. Hyposmia may be due to infection of olfactory epithelium and trigeminal nerves by SARS-CoV-2 [21,22]. Altered mental status is another commonly documented CNS manifestation of COVID-19 and occurred in 92 (19%) of our patients. Prior research suggests that altered mental status is a particularly lethal manifestation of COVID-19, specifically in older adults presenting to the emergency department, in most cases causing acute on chronic neurocognitive dysfunction strongly influenced by systemic inflammation and hypoxic-ischemic mechanisms [5].

Our study identified myalgia and headache as the most common neurological manifestations. Limited information exists regarding the mechanisms and timing of headache in patients with COVID-19. Direct viral invasion of the nervous system as well as the cytokine release syndrome can cause headache. Headache may be due to infection of nasal cavity trigeminal nerve endings and/or endothelial cells in the trigeminovascular system, and/or irritation of trigeminal nerve endings due to increased proinflammatory cytokines [23].

The association of comorbid conditions with neurological manifestations has been reported previously; however, the specific association of comorbid conditions with CNS manifestations, PNS manifestations, and combined CNS/PNS manifestations was unclear. Our study finds that several comorbid conditions were associated with CNS manifestations, though no comorbidities were associated with PNS manifestations. It is unclear whether cardiac disease, hypertension, dementia, and/or COPD made these patients more prone to CNS manifestations or whether systemic inflammation and/or other mechanisms led to CNS involvement.

There are limitations of our study that are worth mentioning. As a retrospective study focused on acute neurological manifestations, we lack information regarding persisting problems and outcomes. Furthermore, we lack data on the results of diagnostic studies that could enhance the results of our findings such as results of serology, electroencephalography, and neuroimaging. We also lack data on patient medications, which could also influence treatment options for COVID-19 manifestations.

Medical comorbidities and neurological manifestations are common in COVID-19 patients. The most common CNS manifestations in our sample were headache and altered mental status. The most common PNS manifestation was myalgia. Comorbid conditions such as cardiac disease, dementia, hypertension, and COPD were more prevalent in patients with CNS manifestations. Future research may further investigate CNS and PNS manifestations and their relationships with laboratory studies, electroencephalography, neuroimaging, medications, and patient outcomes.

Our study provides further evidence of neurological involvement in COVID-19. To our knowledge, there are few studies specifically analyzing the association between medical comorbidities and CNS or PNS manifestations in COVID-19. Providers should be vigilant about the possible emergence of CNS manifestations in COVID-19 patients with cardiac disease, hypertension, dementia, and COPD. Proper management of comorbid disease conditions in patients with COVID-19 may minimize CNS manifestations leading to improved outcomes.

Read this article:
A Study on the Correlations Between Comorbid Disease Conditions and Central and Peripheral Neurological Manifestations of COVID-19 - Cureus

Arthur M. Blank Family Residences. (Photo provided by Shepherd Center)

Shepherd Center a private, not-for-profit hospital in Buckhead has announced the launch of a new campaign that will allow it to serve more of its patients who are suffering from neurological illnesses and injuries.

The $350 million campaign, titled Pursuing Possible: The Campaign for Shepherd Center, will go towards funding capital and programmatic projects that will benefit patients who are experiencing neurological illnesses/injuries such as brain injuries, spinal cord injuries, multiple sclerosis, etc.

Shepherd Center says that one of the ways it will be assisting more patients with neurological illnesses/injuries is by expanding the capacity of its inpatient and outpatient programs.

According to the Atlanta hospital, every year it runs into the issue of not having enough available beds for patients.

In an effort to address this, Shepherd Center says it will be adding 48 more beds to serve more patients on an inpatient basis. As well, Shepherd Center will be expanding its outpatient programs to more effectively assist patients who do not need to be admitted to the hospital.

The hospital says it is able to expand its inpatient and outpatient programs thanks to an $80 million grant from the Marcus Foundation.

In addition to expanding patient care, Shepherd Center also says that the grant will help support the launch of the Marcus Center for Advanced Rehabilitation.

Included in the Marcus Center launch is the addition of a 30,000-square-foot Innovation Institute, a dedicated clinical lab for testing new treatment ideas, an accelerator fund, as well as the hospitals implementation of predictive analytics and artificial intelligence.

Shepherd Center also plans on assisting the families of its patients by doubling the hospitals housing capacity.

Through a capital grant from the Arthur M. Blank Foundation worth $50 million, the grant will allow the hospital to add 160 new accessible units. Through this expansion, more families will be able to stay in housing close by to loved ones who are staying in the hospital, according to Shepherd Center.

When we considered how Shepherd Center needed to grow to fully meet the needs of our patients, their families, our staff, and the community, it was clear that we should expand access to our services, said Sarah Morrison, PT, MBA, MHA, CEO of Shepherd Center.

And we also want to provide a world-class experience with an unparalleled level of recovery for our patients and families as they navigate rehabilitation and achieve their goals for life beyond injury and illness. This expansion will transform the way we provide care to our patients.

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Shepherd Center to assist more patients with neurological illnesses and injuries - Reporter Newspapers