Background: In January 2020, the first case of Guillain Barre syndrome (GBS) due to COVID-19 was documented in China. GBS is known to be postinfectious following several types of infections. Although causality can only be proven through large epidemiological studies, we intended to study this association by a thorough review of the literature. Methods: We searched PubMed, EMBASE, and Google scholar and included all papers with English or Spanish full text and original data of patients with GBS and recent COVID infection. Variables of interest were demographics, diagnostic investigations, and the latency between arboviral and neurological symptoms. Further variables were pooled to identify GBS clinical and electrophysiological variants, used treatments, and outcomes. The certainty of GBS diagnosis was verified using Brighton criteria. Results: We identified a total of 109 GBS cases. Ninety-nine cases had confirmed COVID-19 infection with an average age of 56.07 years. The average latency period between the arboviral symptoms and neurologic manifestations for confirmed COVID-19 cases was 12.2 d. The predominant GBS clinical and electromyography variants were the classical sensorimotor GBS and acute demyelinating polyneuropathy respectively. Forty cases required intensive care, 33 cases required mechanical ventilation, and 6 cases were complicated by death. Conclusions: Studies on COVID-19-related GBS commonly reported sensorimotor demyelinating GBS with frequent facial palsy. The time between the onset of infectious and neurological symptoms suggests a postinfectious mechanism. Early diagnosis of GBS in COVID-19 patients is important as it might be associated with a severe disease course requiring intensive care and mechanical ventilation.
IntroductionFournier‘s gangrene (FG), is a rare life threatening urologic emergency that requires immediate admission of metabolic stabilization and surgical debridement. The mortality rate ranges from 16% to 40%. This study was conducted to investigate the reasons behind the excellent survival rate in our center.Materials and methodA retrospective analysis of the medical records of 20 FG cases from January 2010 to January 2013 was conducted. Data was collected on patients’ comorbidity, survivals, Fournier‘s severity index (FSI) at presentation, length of hospital stay (LOS), the number of intensive care unit (ICU) and operating room (OR) entries, the total phalli and testes removed, colostomies created, and cystostomies performed.ResultsAll 20 cases (100%) collected for the study survived. All patients were male. The median age of the patients was 55.95 years (39–78 year). Only one patient (5%) was admitted to ICU post–operatively. Penile amputation was carried out in three of the 20 cases (15%). The total number of OR entries was 34 (average of 1.7). A majority of 12 patients (60%) were diabetic. A total of six testes were extirpated from the study group. None of the patients required colostomy creation. Only one patient (5%) required a cystostomy tube insertion. FSI was 5.65 ranging from 0 to 14. The average length of hospital stay was 22.3 days.ConclusionIn contrast to what is published in the literature, FG is not rare in our center. Perfect survival rate owes to the moderate severity of the cases treated, but mostly to the urgent surgical intervention with extensive debridement.
Background Mechanical thrombectomy (MT) is the standard treatment for acute large vessel occlusion (LVO). Recurrent LVO can still occur in patients who already underwent MT for the first LVO. This study aimed to evaluate the efficacy of repeating MT for recurrent LVO. Methods This meta-analysis of the available literature was conducted to summarize the current evidence regarding repeated MT outcomes in patients with recurrent LVO. All studies with ≥ 1 outcomes of interest were included. The Newcastle-Ottawa Scale (NOS) was used for risk of bias assessment. Results Twenty studies, 10 observational (n = 21,251 patients) and 10 case reports (n = 10 patients), were included. 266 patients (62.78% females) with recurrent LVO were identified, with an overall prevalence of 1.6% and a mean age of 65.67 ± 16.23 years. Cardio-embolism was the most common mechanism in both times, with a median of 15 days between the first and second LVOs. Compared with pre-intervention, the first and second MTs significantly reduced the National Institute of Health Stroke Scale (NIHSS) score, (mean difference (MD) = −8.91) and (MD = −5.97) respectively, with a significant difference (p = 0.001). The rate of favorable outcome (modified Rankin scale (mRS) score 0–3) was 82.6% and 59.2% after the first and second MTs respectively, with a significant difference (p < 0.001). Conclusion In properly selected recurrent LVO patients, repeated MT is efficacious and safe. A prior MT procedure should not discourage aggressive treatment as many patients may achieve favorable outcomes.
Background High neutrophil–lymphocyte ratio (NLR) is associated with poor survival in lung cancer. This study evaluates whether NLR is associated with baseline brain metastasis in stage IV non-small cell lung cancer (NSCLC). Methods Medical records of stage IV NSCLC patients treated at King Hussein Cancer Center (Amman-Jordan) between 2006 and 2016 were reviewed. Patients with baseline brain imaging and complete blood count (CBC) were included. Receiver operating characteristic (ROC) curve was used to identify the optimal cutoff value for the association between NLR and baseline brain metastasis. Association between age, gender, location of the primary tumor, histology, and NLR was assessed using univariate and multivariate logistic regression analyses. Results A total of 722 stage IV NSCLC patients who had baseline brain imaging were included. Median age was 59 years. Baseline brain metastasis was present in 280 patients (39.3%). Nine patients had inconclusive findings about brain metastasis. The ROC curve value of 4.3 was the best fitting cutoff value for NLR association with baseline brain metastasis. NLR ≥ 4.3 was present in 340 patients (48%). The multivariate analyses showed that high baseline NLR (≥ 4.3) was significantly associated with higher odds of baseline brain metastasis (odds ratio [OR]: 1.6, 95% confidence interval [CI]: 1.2–2.2; p = 0.0042). Adenocarcinoma histology was also associated with baseline brain metastasis (OR: 0.4, 95% CI: 0.25–0.6; p = 0.001). Conclusion High NLR is associated with baseline brain metastasis in advanced-stage NSCLC. In the era of immunotherapy and targeted therapies, whether high NLR predicts response of brain metastasis to treatment is unknown.
ObjectivesTo present our center's experience in managing bladder outlet obstruction (BOO) conditions using bougie dilators. We described the dilation technique methodically for teaching purpose.Patients and methodRetrospectively, a total of 196 medical records over the last four years denoting BOO conditions in men, women, and children were retrieved for analysis. Data reviewed for common complications was namely: perforation, recurrence, urinary tract obstruction (UTI) and inability to overcome the obstruction.ResultsAmong the 196 analyzed cases, 24 (12.2%) cases were cured, whereas 172 (87.8%) cases reported complications. Within the complicated cases analyzed, 134 (68.4%) cases had recurrent obstructions, 13 (6.6%) cases had perforations, 6 (3.0%) cases developed UTI, while in 19 (9.7%) cases, we failed to pass the obstruction.ConclusionsIn our center where urethral dilation technique has revived four years ago, it turned back to be the standard choice in managing BOO cases. We propose the technique to Urology training program directors, all over the world, to teach it as a compulsory skill for junior urologists to master.
Background and Purpose New studies have shown that endovascular thrombectomy (EVT) is safe and effective for acute ischemic stroke (AIS) patients with large ischemic areas. The aim of our study is to conduct a living systematic review and meta-analysis of randomized trials comparing EVT versus medical management only.Methods We searched MEDLINE, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT versus medical management alone in AIS patients with large ischemic regions. We conducted our meta-analysis using fixed-effect models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH) between EVT and standard medical management only. We assessed the risk of bias using the Cochrane risk-of-bias tool and the certainty of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluations approach.Results Of 14,513 citations, we included 3 RCTs with a total of 1,010 participants. We found low-certainty evidence of possibly a large increase in the proportion of patients with functional independence (risk difference [RD] 30.3%, 95% CI 15.0% to 52.3%), low-certainty evidence of possibly a small non-significant decrease in mortality (RD -0.7%, 95% CI -3.8% to 3.5%), and low-certainty evidence of possibly a small non-significant increase in sICH (RD 3.1%, 95% CI -0.3% to 9.8%) for AIS patients with large infarcts who underwent EVT compared to medical management only.Conclusion Low-certainty evidence shows that there is possibly a large increase in functional independence, a small non-significant decrease in mortality, and a small non-significant increase in sICH amongst AIS patients with large infarcts undergoing EVT compared to medical management only.
As COVID-19 vaccines became widely available, there have been reports of neurovascular complications. In this article, we aim to report a case of cerebral venous sinus thrombosis (CVST) induced by COVID-19 vaccination, with a literature review on similar cases as well as the potential pathophysiological mechanisms. Our case is a healthy male who developed headache, vomiting, photophobia and diplopia after receiving the Ad26.COV2.S vaccine. Fundus examination showed papilledema, and magnetic resonance imaging of the brain and cerebral veins showed CVST involving the superior sagittal sinus and right transverse sinus extending into the right jugular vein. Hypercoagulability workup was unremarkable, and the patient received immunotherapy and anticoagulation. Following this treatment, symptoms resolved, and he had no residual neurologic deficits. Developing neurologic manifestations, especially severe headaches with papilledema, after COVID-19 vaccination should warrant neuroimaging. Early recognition and management of CVST are essential for good clinical outcomes.
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