RESUMEN
Preliminary clinical data indicate that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with neurological and neuropsychiatric illness. Responding to this, a weekly virtual coronavirus disease 19 (COVID-19) neurology multi-disciplinary meeting was established at the National Hospital, Queen Square, in early March 2020 in order to discuss and begin to understand neurological presentations in patients with suspected COVID-19-related neurological disorders. Detailed clinical and paraclinical data were collected from cases where the diagnosis of COVID-19 was confirmed through RNA PCR, or where the diagnosis was probable/possible according to World Health Organization criteria. Of 43 patients, 29 were SARS-CoV-2 PCR positive and definite, eight probable and six possible. Five major categories emerged: (i) encephalopathies (n = 10) with delirium/psychosis and no distinct MRI or CSF abnormalities, and with 9/10 making a full or partial recovery with supportive care only; (ii) inflammatory CNS syndromes (n = 12) including encephalitis (n = 2, para- or post-infectious), acute disseminated encephalomyelitis (n = 9), with haemorrhage in five, necrosis in one, and myelitis in two, and isolated myelitis (n = 1). Of these, 10 were treated with corticosteroids, and three of these patients also received intravenous immunoglobulin; one made a full recovery, 10 of 12 made a partial recovery, and one patient died; (iii) ischaemic strokes (n = 8) associated with a pro-thrombotic state (four with pulmonary thromboembolism), one of whom died; (iv) peripheral neurological disorders (n = 8), seven with Guillain-Barré syndrome, one with brachial plexopathy, six of eight making a partial and ongoing recovery; and (v) five patients with miscellaneous central disorders who did not fit these categories. SARS-CoV-2 infection is associated with a wide spectrum of neurological syndromes affecting the whole neuraxis, including the cerebral vasculature and, in some cases, responding to immunotherapies. The high incidence of acute disseminated encephalomyelitis, particularly with haemorrhagic change, is striking. This complication was not related to the severity of the respiratory COVID-19 disease. Early recognition, investigation and management of COVID-19-related neurological disease is challenging. Further clinical, neuroradiological, biomarker and neuropathological studies are essential to determine the underlying pathobiological mechanisms that will guide treatment. Longitudinal follow-up studies will be necessary to ascertain the long-term neurological and neuropsychological consequences of this pandemic.
Asunto(s)
Infecciones por Coronavirus , Enfermedades del Sistema Nervioso , Pandemias , Neumonía Viral , Adolescente , Corticoesteroides/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Betacoronavirus/patogenicidad , COVID-19 , Infecciones por Coronavirus/tratamiento farmacológico , Infecciones por Coronavirus/epidemiología , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Inmunoglobulinas Intravenosas/uso terapéutico , Londres/epidemiología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/líquido cefalorraquídeo , Enfermedades del Sistema Nervioso/diagnóstico por imagen , Enfermedades del Sistema Nervioso/tratamiento farmacológico , Enfermedades del Sistema Nervioso/epidemiología , Neumonía Viral/tratamiento farmacológico , Neumonía Viral/epidemiología , Estudios Retrospectivos , SARS-CoV-2 , Adulto JovenAsunto(s)
Cefaleas Primarias/diagnóstico , Vasoespasmo Intracraneal/diagnóstico por imagen , Adulto , Angiografía por Tomografía Computarizada , Femenino , Cefaleas Primarias/tratamiento farmacológico , Cefaleas Primarias/etiología , Humanos , Nimodipina/uso terapéutico , Vasodilatadores/uso terapéutico , Vasoespasmo Intracraneal/complicaciones , Vasoespasmo Intracraneal/tratamiento farmacológicoRESUMEN
Reported is the case of a 79-year-old woman initially diagnosed with periorbital abscess on the background of a recent upper respiratory tract infection. Unexpectedly, intraoperative findings were that of a haematoma rather than an abscess. Subperiosteal orbital haematoma (SOH) is an extremely rare complication of rhinosinusitis. In contrast to the more common periorbital abscess, it is seldom listed as a complication of sinusitis. A review of reported cases suggests an older patient demographic are affected by SOH in contrast to periorbital abscess which typically affects paediatric patients. Given current demographic trends toward an older patient population with multiple comorbidities, failure to consider SOH as a differential will have important implications on preoperative workup, perioperative care and final outcome for patients. We present this case as a reminder of a rare but important complication of a common disease.
Asunto(s)
Sinusitis Frontal/complicaciones , Hematoma/diagnóstico por imagen , Órbita/patología , Administración Intravenosa , Anciano , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Enfermedades Óseas/complicaciones , Enfermedades Óseas/microbiología , Enfermedades Óseas/patología , Drenaje/métodos , Femenino , Hematoma/tratamiento farmacológico , Hematoma/microbiología , Hematoma/cirugía , Humanos , Órbita/irrigación sanguínea , Enfermedades Orbitales/etiología , Enfermedades Orbitales/patología , Propionibacterium acnes/aislamiento & purificación , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
INTRODUCTION: CT angiography (CTA) is often used for assessing patients with acute ischaemic stroke. Only limited observer reliability data exist. We tested inter- and intra-observer reliability for the assessment of CTA in acute ischaemic stroke. METHODS: We selected 15 cases from the Third International Stroke Trial (IST-3, ISRCTN25765518) with various degrees of arterial obstruction in different intracranial locations on CTA. To assess inter-observer reliability, seven members of the IST-3 expert image reading panel (>5 years experience reading CTA) and seven radiology trainees (<2 years experience) rated all 15 scans independently and blind to clinical data for: presence (versus absence) of any intracranial arterial abnormality (stenosis or occlusion), severity of arterial abnormality using relevant scales (IST-3 angiography score, Thrombolysis in Cerebral Infarction (TICI) score, Clot Burden Score), collateral supply and visibility of a perfusion defect on CTA source images (CTA-SI). Intra-observer reliability was assessed using independently repeated expert panel scan ratings. We assessed observer agreement with Krippendorff's-alpha (K-alpha). RESULTS: Among experienced observers, inter-observer agreement was substantial for the identification of any angiographic abnormality (K-alpha = 0.70) and with an angiography assessment scale (K-alpha = 0.60-0.66). There was less agreement for grades of collateral supply (K-alpha = 0.56) or for identification of a perfusion defect on CTA-SI (K-alpha = 0.32). Radiology trainees performed as well as expert readers when additional training was undertaken (neuroradiology specialist trainees). Intra-observer agreement among experts provided similar results (K-alpha = 0.33-0.72). CONCLUSION: For most imaging characteristics assessed, CTA has moderate to substantial observer agreement in acute ischaemic stroke. Experienced readers and those with specialist training perform best.
Asunto(s)
Isquemia Encefálica/diagnóstico por imagen , Angiografía Cerebral , Accidente Cerebrovascular/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Enfermedad Aguda , Isquemia Encefálica/tratamiento farmacológico , Competencia Clínica , Humanos , Variaciones Dependientes del Observador , Estudios Prospectivos , Reproducibilidad de los Resultados , Accidente Cerebrovascular/tratamiento farmacológico , Terapia TrombolíticaRESUMEN
BACKGROUND AND PURPOSE: In acute ischemic stroke, the hyperdense artery sign (HAS) on noncontrast computed tomography (CT) is thought to represent intraluminal thrombus and, therefore, is a surrogate of arterial obstruction. We sought to assess the accuracy of HAS as a marker of arterial obstruction by thrombus. METHODS: The Third International Stroke Trial (IST-3) was a randomized controlled trial testing the use of intravenous thrombolysis for acute ischemic stroke in patients who did not clearly meet the prevailing license criteria. Some participating IST-3 centers routinely performed CT or MR angiography at baseline. One reader assessed all relevant scans independently, blinded to all other data; we checked observer reliability. We combined IST-3 data with a systematic review and meta-analysis of all studies that assessed the accuracy of HAS using angiography (any modality). RESULTS: IST-3 had 273 patients with baseline CT or MR angiography and was the largest study of HAS accuracy. The meta-analysis (n=902+273=1175, including IST-3) found sensitivity and specificity of HAS for arterial obstruction on angiography to be 52% and 95%, respectively. HAS was more commonly identified in proximal than distal arteries (47% versus 37%; P=0.015), and its sensitivity increased with thinner CT slices (r=-0.73; P=0.001). Neither extent of obstruction nor time after stroke influenced HAS accuracy. CONCLUSIONS: When present in acute ischemic stroke, HAS indicates a high likelihood of arterial obstruction, but its absence indicates only a 50/50 chance of normal arterial patency. Thin-slice CT improves sensitivity of HAS detection. CLINICAL TRIAL REGISTRATION URL: http://www.controlled-trials.com/ISRCTN25765518. Unique identifier: ISRCTN25765518.