Hypoglossal nerve palsy after SARS-CoV-2 vaccination – report of two cases

Background

SARS-CoV-2 vaccination is associated with an increased risk for Bell’s palsy and some other neurological disorders assumed to be of autoimmune origin. While facial nerve palsy is frequent and usually idiopathic, hypoglossal nerve palsy is rare, and a specific cause is almost always found. We firstly report two patients who developed isolated hypoglossal nerve palsy shortly after SARS-CoV-2 vaccination.

Case presentation

Two otherwise healthy patients, a 49-year-old man and a 39-year-old woman, developed unilateral hypoglossal nerve palsy 10 and 7 days after the second SARS-CoV-2-vaccination (AstraZeneca and BioNTech/Pfizer), respectively. In both subjects, needle electromyography showed denervation and rarefication of motor units. CT, MRI, examination of blood and CSF as well as ENT exam were unremarkable. In both subjects symptoms gradually improved.

Conclusion

Due to close temporal relationship, the absence of other etiologies, and spontaneous improvement we suspect the vaccination as the cause for hypoglossal nerve palsy in both patients. This is further supported by the rarity of isolated hypoglossal nerve palsies, especially in idiopathic cases. We suggest the addition of hypoglossal nerve palsy to the list of neurological injuries potentially caused by SARS-CoV-2 vaccination.

[Zika virus infection and the nervous system]

Zika virus is an arbovirus from the family of flaviviruses, which is transmitted by the mosquito Aedes aegyptii and also by the Asian mosquito Aedes albopticus. The largest observed Zika virus epidemic is currently taking place in North and South America, in the Caribbean, southern USA and Southeast Asia. In most cases the infection is an unspecific, acute, febrile disease. Neurological manifestations consist mainly of microcephaly in newborns and Guillain-Barré syndrome but other rare manifestations have also become known in the meantime, such as meningoencephalitis and myelitis. Therefore, the Zika virus, similar to other flaviviruses, has neuropathogenic properties. In particular, the drastic increase in microcephaly cases in Brazil has induced great research activities. The virus is transmitted perinatally and can be detected in the amniotic fluid, placenta and brain tissue of the newborn. Vaccination or a causal therapy does not yet exist. The significant increase in Guillain-Barré syndrome induced by the Zika virus was observed during earlier outbreaks. In the meantime, scientifically clear connections between a Zika virus infection and these neurological manifestations have been shown. Long-term studies and animal models should be used for a better understanding of the pathomechanisms of this disease.

123I-FP-CIT SPECT imaging of the dopaminergic state

123I-N-ω-fluoropropyl-2β-carbomethoxy-3β- (4-iodophenyl)nortropan (123I-FP-CIT) single photon emission computed tomography (SPECT) can be evaluated by both visual assessment and quantitative analysis to assess the striatal dopamine state in vivo. The aim of our study was to investigate if visual assessment according to a predefined image grading scale reflects the results of quantitative assessment techniques. Patients, methods: 195 patients with a clinical diagnosis of idiopathic Parkinson's disease (n = 134), atypical parkinsonian syndrome (n = 47) or essential tremor (n = 14) were examined with 123I-FP-CIT SPECT and included in this retrospective study. Results were analysed according to predefined visual patterns of dopaminergic degeneration and graded as normal (grade 5) or abnormal (grade 1–4) independently by three raters. Quantitative two-dimensional (2D) operator-dependent, manual and three-dimensional (3D) operator- independent, automated approaches were used for quantitative analysis of the specific 123I-FP-CIT tracer binding ratio (SBR) for caudate and putamen. Results: Sensitivity, specificity, PPV, NPV and diagnostic accuracy of visual assessment of 123I-FP-CIT SPECT for the diagnosis of a neuro degenerative Parkinson's syndrome were 99%, 86%, 99%, 86% and 98%, respectively. Visual assessment and quantitative analysis agreed well in evaluating the degree of dopaminergic degeneration. Significant differences (p < 0.001) were found between degeneration patterns. Only between the so-called eagle wing degeneration and the normal pattern no significant differences in SBR caudate and putamen were found, neither by the quantitative manual (p = 1.00; p = 0.196) nor by the quantitative automated method (p = 1.0; p = 0.785). Inter-rater agreement for visual assessment was substantial for all possible pairs of the three raters (κ = 0.70 to 0.74). Strong correlations were observed between the quantitative manual and quantitative automated methods for quantification of SBR caudatum (r = 0.920, r2 = 0.846, p < 0.001) and SBR putamen (r = 0.908, r2 = 0.824, p < 0.001). Conclusion: Visual assessment was highly consistent with the results obtained by quantitative analysis and showed a substantial inter-rater agreement between experienced and inexperienced raters. Our findings indicate that visual assessment might be a reliable analysis approach for clinical routine.

Deep brain stimulation and cognitive decline in Parkinson's disease: The predictive value of electroencephalography

Some Parkinson's disease (PD) patients treated with subthalamic nucleus deep brain stimulation (STN-DBS) develop new-onset cognitive decline. We examined whether clinical EEG recordings can be used to predict cognitive deterioration in PD patients undergoing STN-DBS. In this retrospective study, we used the Grand Total EEG (GTE)-score (short and total) to evaluate pre- and postoperative EEGs. In PD patients undergoing STN-DBS (N = 30), cognitive functioning was measured using Mini-Mental State Test and DemTect before and after surgery. Severity of motor impairment was assessed using the Unified Parkinson's Disease Rating Scale-III. Patients were classified into patients with or without cognitive decline after STN-DBS surgery. Epidemiological data, pre- and postoperative EEG recordings as well as neuropsychological and neurological data, electrode positions and the third ventricle width were compared. A logistic regression model was used to identify predictors of cognitive decline. Motor deficits significantly improved from pre- to post-surgery, while the mean GTE-scores increased significantly. Six patients developed cognitive deterioration 4-12 months postoperatively. These patients had significantly higher preoperative GTE-scores than patients without cognitive deterioration, although preoperative cognitive functioning was comparable. Electrode positions, brain atrophy and neurological data did not differ between groups. Logistic regression analysis identified the GTE-score as a significant predictor of postoperative cognitive deterioration. Data suggest that the preoperative GTE-score can be used to identify PD patients that are at high risk for developing cognitive deterioration after STN-DBS surgery even though their preoperative cognitive state was normal.

Subjectively perceived personality and mood changes associated with subthalamic stimulation in patients with Parkinson's disease

BACKGROUND

Clinical and ethical implications of personality and mood changes in Parkinson's disease (PD) patients treated with subthalamic deep brain stimulation (STN-DBS) are under debate. Although subjectively perceived personality changes are often mentioned by patients and caregivers, few empirical studies concerning these changes exist. Therefore, we analysed subjectively perceived personality and mood changes in STN-DBS PD patients.

METHOD

In this prospective study of the ELSA-DBS group, 27 PD patients were assessed preoperatively and 1 year after STN-DBS surgery. Two categories, personality and mood changes, were analysed with semi-structured interviews. Patients were grouped into personality change yes/no, as well as positive/negative mood change groups. Caregivers were additionally interviewed about patients' personality changes. Characteristics of each group were assessed with standard neurological and psychiatric measurements. Predictors for changes were analysed.

RESULTS

Personality changes were perceived by six of 27 (22%) patients and by 10 of 23 caregivers (44%). The preoperative hypomania trait was a significant predictor for personality change perceived by patients. Of 21 patients, 12 (57%) perceived mood as positively changed. Higher apathy and anxiety ratings were found in the negative change group.

CONCLUSIONS

Our results show that a high proportion of PD patients and caregivers perceived personality changes under STN-DBS, emphasizing the relevance of this topic. Mood changed in positive and negative directions. Standard measurement scales failed to adequately reflect personality or mood changes subjectively perceived by patients. A more individualized preoperative screening and preparation for patients and caregivers, as well as postoperative support, could therefore be useful.

VEGF transfer based on gene-modified fibroblasts using a hypoxia-induced vector to modulate neoangiogenesis in ischaemic regions of myocutaneous transplants

The effect of a hypoxia-inducible VEGF-expressing on wound healing in an ischaemic hind leg rat model was evaluated in this study. 180 Wistar rats were assigned randomly to three groups. After ligation of the femoral artery, group 1 received pRTP801-VEGF165, group 2 untransfected fibroblasts, group 3 saline; injection was into the subcutaneous tissue, proximal and distal to the artery ligation. Biopsy specimens were obtained on days 3, 5, 7, 14 after implementation. VEGF transgene expression, vessel architecture, the amount and total area of vessel formation were investigated. Results showed a significantly higher level of VEGF protein expression in group 1 compared to group 2 (P≤0.001) throughout the investigational period. Group 1 exhibited a significant growth of CD31-positive blood vessels in the subcutaneous tissue on day 14 compared to groups 2 and 3 (P≤0.001) (group 1, 62.20±1.92; group 2, 20.60±1.67; group 3, 12.40±1.14). Alpha-SMA-positive staining also showed significant vessel growth in group 1 on day 5 (group 1, 27.00±1.87; group 2, 7.20±1.48; group 3, 10.00±1.73). These results were confirmed in the distal muscle tissue. No significant results were obtained for the proximal muscle tissue. The subcutaneous application of pRTP801-VEGF165 showed a long-lasting effect, with an increased expression of VEGF over the entire observation period. It appears that the use of fibroblasts transfected with VEGF is a promising way to increase early angiogenesis in ischaemic tissue.

P1-02-06: Silencing of IGF-1R Has Paradoxical Effects in Triple Negative Breast Cancer Phenotypes

Background: Triple negative (TN) breast cancers are a heterogeneous group of breast cancers with a poor prognosis in part due to a lack of effective targeted agents. Insulin-like growth factor-1 receptor (IGF-1R) has been shown to play a role in breast cancer cell proliferation, adhesion, invasion, and migration and is overexpressed in more than a third of TN breast tumors. We hypothesized that IGF-1R could be a therapeutic target for a subset of TN breast cancers. Methods: We evaluated the effects of IGF-1R silencing on the metastatic properties of TN breast cancer cells by knock down in two morphologically distinct TN breast cancer cell lines using shRNA lentiviral techniques. Reverse-transcription polymerase chain reaction (RT-PCR) and immunoblotting were used to detect mRNA and protein expression levels, respectively, of IGF-1R signaling molecules. Anchorage-dependent growth and Matrigel chamber assays were performed to assess the effects of IGF-1R silencing on colony formation and invasion of TN breast cancer cells, respectively; wound-healing and spheroid migration were also performed to assess the effects of IGF-1R inhibition on TN breast cancer cell motility. Results: Stably transfected mesenchymal MDA-MB-231 TN cells showed effective downregulation of IGF-1R protein expression, which resulted in mesenchymal-to-epithelial transition (MET), confirmed by upregulation of the epithelial marker E-cadherin and downregulation of the mesenchymal marker vimentin. Importantly, this MET resulted in reduced colony formation (p&lt;0.0042) and cell motility and dramatically reduced invasion (p&lt;0.0001). Conversely, silencing of IGF-1R in epithelial MDA-MB-468 TN cells induced epithelial-to-mesenchymal transition (EMT), confirmed by downregulation of E-cadherin and upregulation of vimentin expression, with resultant increased colony formation (p&lt;0.006), cell motility, and invasion (p&lt;0.0001). Conclusion: Collectively, these results demonstrate a paradoxical effect of targeting IGF-1R in TN breast cancers of mesenchymal and epithelial origin. Targeting IGF-1R in TN breast cancers with a mesenchymal phenotype decreases invasion and metastatic potential. In contrast, targeting IGF-1R in TN breast cancers with an epithelial phenotype could have potentially detrimental effects. Our data suggest that IGF-1R inhibition should be explored as a therapeutic modality in TN breast cancers with a mesenchymal phenotype.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-02-06.

[Diagnostic work-up in Whipple's disease with cerebral involvement]

The diagnostic work-up in the case of a suspected cerebral involvement of Whipple's disease involves neuroimaging and analysis of cerebrospinal fluid (CSF) including polymerase chain reaction (PCR) assays for Tropheryma whipplei. As neurological findings may be complex and unspecific, extracerebral symptoms often lead to the suspicion of Whipple's disease. We report the cases of two patients in whom the suspected diagnosis of Whipple's disease could not be proved either by endoscopy or by the analysis of CSF. Only by means of a cerebral biopsy was the diagnosis assumed and specific therapy was initiated.

[Acute headache: limitations of cerebral computed tomography and analysis of cerebrospinal fluid in the diagnosis of subarachnoid haemorrhage]

Subarachnoid haemorrhage constitutes a neurological emergency. In most cases the diagnosis is easy to establish by cerebral computed tomography or cerebrospinal fluid tap. However, in rare cases verification of the diagnosis is more difficult and a residual uncertainty remains. We describe three patients supposed to have a subarachnoid haemorrhage without pathological findings in both cerebral computed tomography and cerebrospinal fluid. In these cases vasospasm or cerebral aneurysm were detected by means of transcranial Doppler sonography and/or conventional angiography. We comment on the special features of this rare presentation of a severe acute neurological emergency, and we discuss diagnostic work-up and differential diagnoses.

[Thrombolytic therapy in conversion disorder with sensorimotor hemisyndrome]

We here report on a 43-year-old man who was repeatedly admitted to our stroke unit with acute onset of sensorimotor hemisyndrome of acute onset. In most cases symptoms ceased shortly after admission, but twice when symptoms persisted thrombolytic therapy was applied. This case demonstrates that in emergency situations a rare differential diagnosis like conversion disorder with sensorimotor deficits may be hard to establish even if the patient presents to the same emergency unit.

Progression of subtle motor signs in PINK1 mutation carriers with mild dopaminergic deficit

BACKGROUND

While homozygous mutations in the PINK1 gene cause recessively inherited early-onset Parkinson disease (PD), heterozygous mutations have been suggested as a susceptibility factor.

METHODS

To evaluate this hypothesis, 4 homozygous PINK1 patients with PD and 10 asymptomatic carriers of a single heterozygous mutation from a large German family (family W) were included in this study. Clinical follow-up of the heterozygous mutation carriers 3 years after the initial visit included a detailed videotaped neurologic examination using the Unified Parkinson's Disease Rating Scale III protocol and smell and color discrimination testing. At follow-up, PET with 18-fluorodopa (FDOPA) of 13 family members was obtained in order to evaluate the clinical phenotype in light of nigostriatal dopaminergic functioning. The clinical and PET data were compared to those of healthy controls.

RESULTS

While there was mild worsening of clinical signs in previously affected heterozygous mutation carriers upon follow-up, 3 additional individuals had newly developed signs of possible PD. Hyposmia was found in 7 of the heterozygous mutation carriers, diminished color discrimination in 4. The homozygous mutation carriers who were all definitely affected with PD showed a severe, 60% decrease of caudate and putaminal FDOPA uptake; heterozygous offspring also had a significant 20% putaminal FDOPA uptake reduction compared to controls.

CONCLUSIONS

Our findings strengthen the hypothesis that heterozygous PINK1 mutations act as a susceptibility factor to develop at least subtle Parkinson disease motor and nonmotor signs, as supported by the finding of a reduced striatal dopaminergic FDOPA uptake not only in homozygous but also, albeit to a lesser extent, in heterozygous mutation carriers.

[Mistaking a long QT syndrome for epilepsy: does every seizure call for an ECG?]

Syncope is a common and difficult differential diagnosis for epilepsy. One possible cause for a cardiac syncope is a long QT syndrome (LQTS). LQTS with torsade de pointes tachycardia can lead to lethal ventricular fibrillation and cardiac arrest. Patients with LQTS when first diagnosed as suffering from epileptic fits often experience a particularly long diagnostic delay which may even take years. In some cases, the diagnosis of LQTS is not made until the patient needs resuscitation due to a cardiac arrest. Therefore, ECG recording should be performed for every patient presenting with a seizure considered to be of epileptic origin not only at the beginning of the disease but also when fits occur in spite of antiepileptic treatment in order to prevent an incorrect diagnosis and delay in making the correct diagnosis.

Neurotransmitter changes in dementia with Lewy bodies and Parkinson disease dementia in vivo

OBJECTIVE

Although Parkinson disease with dementia (PDD) and dementia with Lewy bodies (DLB) show a wide clinical and neuropathologic overlap, they are differentiated according to the order and latency of cognitive and motor symptom appearance. Whether both are distinct disease entities is an ongoing controversy. Therefore, we directly compared patients with DLB and PDD with multitracer PET.

METHODS

PET with (18)fluorodopa (FDOPA), N-(11)C-methyl-4-piperidyl acetate (MP4A), and (18)fluorodeoxyglucose (FDG) was performed in 8 patients with PDD, 6 patients with DLB, and 9 patients with PD without dementia vs age-matched controls. Data were analyzed with voxel-based statistical parametric mapping and region of interest-based statistics.

RESULTS

We found a reduced FDOPA uptake in the striatum and in limbic and associative prefrontal areas in all patient groups. Patients with PDD and patients with DLB showed a severe MP4A and FDG binding reduction in the neocortex with increasing signal diminution from frontal to occipital regions. Significant differences between PDD and DLB were not found in any of the radioligands used. Patients with PD without dementia had a mild cholinergic deficit and no FDG reductions vs controls.

CONCLUSIONS

Patients with dementia with Lewy bodies and Parkinson disease dementia share the same dopaminergic and cholinergic deficit profile in the brain and seem to represent 2 sides of the same coin in a continuum of Lewy body diseases. Cholinergic deficits seem to be crucial for the development of dementia in addition to motor symptoms. The spatial congruence of cholinergic deficits and energy hypometabolism argues for cortical deafferentation due to the degeneration of projection fibers from the basal forebrain.

Evaluation of 2 Years’ Residential Care Treatment for Adolescents and Young Adults with Schizophrenia

Aims:

In 2002 the Professor Eggers Foundation started a 2-year-programme for patients suffering from early-onset schizophrenia (EOS) following discharge from a clinic (outpatient care). The aim is with intense residential care and treatment to support recovery and independence. Interactive and psychoeducational family care, coping with persistent symptoms, development of social and emotional competence, independent house keeping, and support of school and vocational training are the main features.

Methods:

Psychopathology, social and neuropsychological function were assessed with a set of questionnaires and tests at the start, after 1 year and after 2 years on completion of the programme for 12 participants. Living and working situation were monitored. The results were compared with the progress of 12 EOS patients treated as usual (comparison group).

Results:

Positive and negative symptoms showed a significantly greater decrease with respect to the comparison group. Social function improved considerably stronger in the participants. Working memory, attention and some executive functions also improved in the participants, while there was a deterioration of speed and selective attention (trend) in the comparison group. Neither group showed changes in measures of intelligence or the subjective quality of life with the exception of increased contentedness with family relations in the participants.

Conclusions:

We show the benefits of an early intensive residential training programme for EOS patients. Further research may be able to show if these improvements can be maintained and whether the costs of the programme are economical avoiding continued residential care.

Komplikationen bei operativer Dekompression an der tumorinfiltrierten Wirbelsäule

INTRODUCTION

This study evaluated the intra- and post-surgical complications on tumor affected spines. Complications were analyzed according to selected patient groups so that risk factors could be determined.

MATERIAL AND METHODS

Between January 1999 and December 2004, 401 patients underwent surgery because of spinal metastases in the Department of Traumatology, General Hospital St. Georg in Hamburg. Data were obtained from the hospital's documentary system. The results of this study were compared to other published studies.

RESULTS

The average age of patients was 63 years (24-88) and there were 172 (42.9%) females and 229 (57.1%) males. A total of 118 (29.4%) patients suffered from 235 complications and 22 (5.5%) died.

DISCUSSION

Patient's age >70 years, patients with a preoperative neurological deficit, and patients with heavily bleeding metastases are at high risk for complications. The dorsoventral/dorsolateral approach had the highest complication rate.

Imaging of acetylcholine esterase activity in brainstem nuclei involved in regulation of sleep and wakefulness

Positron emission tomography with 11C-N-methyl-4-piperidyl-acetate (MP4A) was applied in eight healthy volunteers and two patients with mild Alzheimer's disease (AD) to assess acetylcholine esterase (AChE) activity in magnetic resonance imaging-identified brainstem nuclei. Uptake ratios in lateral dorsal tegmental and pedunculopontine nuclei relative to cerebellum yielded reproducible values for the AChE activity in controls and reduced values in AD, more marked in a patient with complaints of disturbed sleep. Cortical AChE activity was related to the extent of cognitive impairment which was more severe in the AD patient without sleep disturbance. This preliminary observational study demonstrates the feasibility to image and assess AChE activity in small nuclei of the brain stem. This approach may be helpful to investigate the interaction of various nuclei in the complex network regulating sleep and wakefulness in representative patient groups with documented sleep disturbance.

Ergebnisse nach Versorgung instabiler proximaler Humerusfrakturen mittels winkelstabiler Platte

BACKGROUND

Fixed-angle implants are being increasingly used in surgery of fractures of the proximal humerus. The aim of this retrospective investigation was to evaluate the outcome after fracture reduction utilizing a fixed-angle plate (Königsee).

MATERIALS AND METHODS

Between January 2003 and April 2004, 58 patients were operated, 52 of whom received a fixed-angle implant; 46 cases were harvested for a follow-up examination. Each patient was re examined clinically and radiologically at least 6 and 18 months after surgery. The functional outcome was evaluated using the Constant Score and the Simple Shoulder Test. The results were compared to results of other investigations.

RESULTS

The mean patient age was 68.8 years (34-94 years). Fractures were classified using the Neer Classification: 12 were classified as two-part, 25 as three-part, and 9 as four-part fractures. Three of the three-part and four of the four-part fractures were rated as luxation fractures. The overall functional outcome of all cases was good. More than 18 months after surgery the mean general "Constant Score" was 57; the mean side-related "Constant Score" was 89%. The Simple Shoulder Test revealed a pain-free range of motion in 41 (89.1%) of the individuals. The majority of the patients were satisfied with the results regarding remaining range of activity of the injured limb. In five cases significant complications occurred. In two cases the head of the humerus collapsed, and in one case a necrosis of the head occurred. In one individual the implant broke after an additional trauma. In this case a re-osteosynthesis utilizing a tibia plate was performed and the patient was excluded from further follow-up investigations. One soft tissue infection occurred after initial surgery.

CONCLUSION

It has been shown that results after fixation of proximal humerus fractures with fixed-angle implants are good. The functional outcome is good and complications are rare. Our results correlate with other investigations regarding fracture reduction using fixed-angle plates and nails.