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Objective The objective of this study was to describe the documented neurological assessment and investigations for neuroprognostication in patients after cardiac arrest. Design, setting, and participants This was a retrospective cohort study of adult patients after cardiac arrest, admitted to a tertiary intensive care unit (ICU), between January 2009 and December 2018. Main outcome measures The main outcome measures were the proportion of patients with a documented Glasgow Coma Scale (GCS) score and investigations for neuroprognostication. Results Four hundred twenty-seven patients formed the study cohort. The GCS score was documented for 267 (63%) patients at some time during their ICU stay. The proportion of patients with the GCS score documented decreased each day of ICU stay (59% at day 1, 20% at day 5). Pupil reflex to light was recorded in 352 (82%), corneal reflex in 155 (36%), and limb reflexes in 216 (51%) patients. Twenty-eight (6.6%) patients underwent brain magnetic resonance imaging, 10 (2.3%) an electroencephalogram, and two somatosensory evoked potentials. Withdrawal of life-sustaining treatments occurred in 166 (39%) patients, and 221 (52%) patients died in hospital. Conclusions In this single-centre study of patients admitted to the ICU after cardiac arrest, the GCS score was inconsistently documented, and investigations for neuroprognostication were infrequent.

Вивчено нейрофізіологічні аспекти функціонального стану стовбурових структур головного мозку в пацієнтів з хронічною ішемією головного мозку. Аналіз параметрів мигального рефлексу дає можливість оцінювати динаміку та контролювати результати проведеної терапії. Дослідження мигального рефлексу виявило в більшості пацієнтів із хронічною церебральною ішемією ознаки порушення функції стовбура мозку, що нівелюються після призначення Церебролізину.

Abnormal blink reflex (BR) results mainly from the dysfunction of reticular brainstem pathways and is one of the features of degenerative brain disorders. We aimed to investigate whether patients with Wilson’s disease (WD) have abnormal BR. This was a prospective, observational, single-center study. BR was assessed in accordance with generally accepted standards in 44 newly diagnosed treatment-naïve and 66 treated patients with WD. Any abnormal parameters in BR were observed in 45.5% treatment-naïve patients and 37.9% treated patients (p = 0.429). We also did not observe significant differences in BR parameters and frequency of abnormal findings between treated and treatment naïve patients. Abnormal findings in any of the BR parameters were more frequent in patients with neurological vs. non-neurological presentation (57.5 vs. 28.6%, p = 0.002), present vs. absent Kayser–Fleischer ring (73 vs. 21.5%, p p = 0.009). In addition, longer median R1 and R2 latencies, both ipsilateral and contralateral, were significantly more frequent in neurological than non-neurological WD patients, those with Kayser–Fleischer rings, and those with abnormal MRI findings typical of WD. Our results confirm frequent BR abnormalities in WD, which may be explained by the pathological influence of copper deposits in the circuit linking the basal ganglia, cerebellum and brainstem.

Aim of the work To study the frequency of cranial and peripheral neuropathies in systemic lupus erythematosus (SLE), their clinical characteristics, electrophysiological pattern and relation to disease activity. Patients and methods The study included 30 SLE patients and 20 matched healthy controls. Electrophysiological assessment included routine nerve conduction studies for assessment of peripheral nerves and visual evoked potential, blink reflex, and brain stem auditory evoked potential for assessment of the second, fifth, seventh, and eighth cranial nerves, respectively. Safety of Estrogens in Lupus Erythematosus National Assessment–SLE Disease Activity Index (SELENA–SLEDAI) was assessed. Results The mean age of the patients was 35.8 ± 8.6 years, 27 females and 3 males (9:1) with median disease duration 4.5(1.2–8) years and SELENA-SLEDAI of 12.09 ± 4.94. The mean complement-3 (C3) level was 81.2 ± 26.9 mg/dl and C4 was 11.5 ± 4.4 mg/dl. Peripheral neuropathy was detected electrophysiologically in 66.7% and clinically in 53.3% of the patients and was sensory more than motor. Sensory neuropathy was found in 9(30%), sensorimotor in 11(36.7%), demyelinating in 9(30%), axonal in 6(20%) and both axonal and demyelinating in 5(16.7%) patients. 13.3% had subclinical neuropathy. Sensorimotor and sensory neuropathies were detected in 36.7% and 30% of patients, respectively. Cranial neuropathy was not detected in any patient or control clinically or electrophysiologically. Peripheral neuropathy significantly correlated with SELENA-SLEDAI (r = 0.55, p = 0.002) and negatively with C3 and C4 (r = −0.65, p = 0.012 and r = −0.63, p = 0.015 respectively). Conclusion Peripheral neuropathy is a well-recognized but underestimated manifestation of neuropsychiatric SLE with predominance of sensorimotor variant. Peripheral neuropathy is associated with disease activity and complement consumption.

Objective To investigate the effects on the blink reflex (BR) of single stimuli applied to the pedunculopontine tegmental nucleus (PPTg). Methods The BR was evoked by stimulating the supraorbital nerve (SON) in fifteen patients suffering from idiopathic Parkinson’s disease (PD) who had electrodes monolaterally or bilaterally implanted in the PPTg for deep brain stimulation (DBS). Single stimuli were delivered to the PPTg through externalized electrode connection wires 3–4 days following PPTg implantation. Results PPTg stimuli increased the latency and reduced duration, amplitude and area of the R2 component of the BR in comparison to the response recorded in the absence of PPTg stimulation. These effects were independent of the side of SON stimulation and were stable for interstimulus interval (ISI) between PPTg prepulse and SON stimulus from 0 to 110 ms. The PPTg-induced prepulse inhibition of the BR was bilaterally present in the brainstem. The R1 component was unaffected. Conclusions The prepulse inhibition of the R2 component may be modulated by the PPTg. Significance These findings suggest that abnormalities of BR occurring in PD may be ascribed to a reduction of basal ganglia-mediated inhibition of brainstem excitability.

This prospective study was designed to assess whether patients with skeletal deformities show characteristic masseter inhibitory reflex (MIR) and blink reflex (BR) patterns. A secondary aim was to investigate whether these reflexes change following bilateral sagittal split osteotomy (BSSO).Fourteen consecutive patients who underwent single-jaw BSSO and 14 class I subjects who constituted the control group were enrolled into the study. MIR and BR, obtained by the stimulation of supraorbital (SBR) and mental nerves (MBR), were electrophysiologically recorded. Sensory impairment in the mental nerve distribution was clinically tested. Three evaluation periods were specified as immediately before (T0), 1 month (T1) and 6 months (T2) after surgery.MIR early silent period duration was significantly shorter in the patients at T0 (p 0.001). Sensory deficits developed on 23 sides after BSSO, of which, 17 recovered after 6 months. At T1, MBR was inelicitable bilaterally in 3 patients and unilaterally in 2 patients. These responses were still unrecordable bilaterally in 1 patient, and unilaterally in 4 patients at T2. MIR were unrecordable on 18 sides at T1 and recovered on 11 sides at T2. There were no parallels between the clinical sensory deficits and the abnormal results of the reflexes.Shorter MIR in patients with dentofacial abnormalities may be a reflection of an adapted trigeminal reflex mechanism. Although MBR and MIR abnormalities do not develop parallel to the clinical sensory deficits, their course might provide insights into the disturbed trigeminal reflex pathways.ZIELSETZUNGEN: In dieser prospektiven Studie sollte untersucht werden, ob Patienten mit Skelettdeformitäten charakteristische Muster des inhibitorischen Masseterreflexes (MIR) und des Blinzelreflexes (BR) aufweisen. Ein weiteres Ziel war es, zu untersuchen, ob sich diese Reflexe nach einer bilateralen sagittalen Spaltosteotomie (BSSO) verändern.Vierzehn konsekutiv aufgenommene Patienten, die sich einer monomaxillären BSSO unterzogen hatten, und 14 Klasse-I-Patienten, welche die Kontrollgruppe bildeten, wurden in die Studie aufgenommen. Der MIR sowie durch Stimulation des N. supraorbitalis (SBR) und des N. mentalis (MBR) getriggerte BR wurden elektrophysiologisch aufgezeichnet. Die sensorischen Beeinträchtigungen im Bereich des N. mentalis wurden klinisch untersucht. Drei Bewertungszeiträume wurden festgelegt: unmittelbar vor (T0), 1 Monat (T1) und 6 Monate (T2) nach der Operation.Die Dauer der frühen, silenten Phase des MIR war bei den Patienten bei T0 signifikant kürzer (p 0,001). Nach der BSSO entwickelten sich auf 23 Seiten sensorische Defizite, von denen sich 17 nach 6 Monaten erholten. Zum Zeitpunkt T1 war der MBR bei 3 Patienten beidseitig und bei 2 Patienten einseitig nicht auslösbar. Bei T2 waren diese Reaktionen bei einem Patienten bilateral und bei 4 Patienten unilateral nicht mehr nachzuweisen. Der MIR war bei T1 auf 18 Seiten nicht nachweisbar und bei T2 auf 11 Seiten wieder vorhanden. Es gab keine Parallelen zwischen den klinischen sensorischen Defiziten und den abnormalen Ergebnissen der Reflexe.Ein kürzerer MIR bei Patienten mit dentofazialen Anomalien kann Ausdruck eines angepassten Trigeminusreflexmechanismus sein. Auch wenn sich die MBR- und MIR-Anomalien nicht parallel zu den klinischen sensorischen Defiziten entwickeln, könnte ihr Verlauf Aufschluss über die gestörten trigeminalen Reflexbahnen geben.

Background Ptosis can be a manifestation of a more serious situation. Hence, the analysis of the complaint and the search for etiology are crucial in such cases. Ptosis has many causes; some of them lead to unilateral ptosis while others cause bilateral ptosis. For instance, myasthenia gravis is a cause of bilateral ptosis while oculomotor nerve palsy induces unilateral disease. Proper evaluation of the patient and identification of the cause are important to achieve accurate management and good prognosis. Case presentation A 47-year-old male patient attended the ER complaining of dropping the right eye lid of 2 days’ duration. There was no associated pain or diplopia. On examination, the extraocular muscles’ (EOM) motility was intact, normal pupil and corneal reflexes, and there was swelling of the upper eyelid. Ophthalmological examination revealed normal anterior and posterior chambers as well as the vitreous and retina. The patient had a previous history of traumatic intracranial hemorrhage that was resolved without surgical intervention. He also had diabetes mellitus and hypertension. The patient was transferred to the MRI unit to perform MRI study of the brain and orbit with MRA and IV contrast administration. MRI findings confirmed the diagnosis of LPS myositis, and the patient received medical treatment and improved. Conclusion Proper radiological diagnosis leads to accurate management and achieves rapid recovery and optimal patient care.

Raffaele Migliorini,1 Anna Maria Comberiati,1 Fernanda Pacella,1 Anna Rosy Longo,1 Daniela Messineo,2 Edoardo Trovato Battagliola,1 Mariaelena Malvasi,1 Elena Pacella,1 Loredana Arrico1 1Department of Sense Organs, University Sapienza, Rome, Italy; 2Department of Radiology, Oncology, and Anatomopathological, University Sapienza, Rome, ItalyCorrespondence: Elena PacellaDepartment of Sense Organs, University Sapienza, Policlinico Umberto I, Viale del Policlinico 155, Rome, 00161, ItalyTel +39 336783409Email elena.pacella@uniroma1.itPurpose: Determine the usefulness of ocular motility testing to detect the presence of muscle entrapment.Materials and Methods: Cross-sectional study of patients with symptoms of diplopia secondary to facial trauma. Inclusion criteria: age between 20 and 80 years; symptoms of diplopia following facial trauma; presence of orbital floor fracture confirmed radiologically; presence of muscle entrapment confirmed at the time of surgery; best-corrected visual acuity of 0.6 or more. Exclusion criteria: muscle entrapment visible on computed tomography; candidate for immediate surgical correction; prior history of strabismus surgery. Outcome measures: Abnormal Head Position (AHP), Hirschberg Corneal Reflexes (CR), Cover/Uncover and Alternating Cover Test, Hertel exophthalmometry, Near Point of Convergence (NPC), Kestenbaum Limbus test, Red Filter test, and Hess screen test.Results: Forty-six subjects (38 males, 8 females, mean age 27 ± 3.3 SD years). Pre-operative assessment: forty-six (100%) reported diplopia on the Red Filter test and showed some degree of abnormality on the Hess Screen test. Forty-two (91%) showed AHP. Forty-one (89%) had exophthalmometry values that differed 2 mm or more between the two eyes and insufficient NPC. Thirty-two (69.6%) showed deficits of 3 mm or more on the Kestenbaum Limbus test. Sixteen (35%) had abnormal Hirschberg corneal reflexes. Eleven (24%) demonstrated constant or intermittent strabismus.Conclusion: Ocular motility testing can differentiate non-invasively, pre-operatively, and cost-effectively the presence of muscle entrapment even when this is not visible on computed tomography.Keywords: orbital blow-out fractures, orbital floor fracture, ocular motility, trauma, delayed surgical repair, muscle entrapment, traumatic diplopia

Introduction The aim of this study was to analyze the functions of pedunculopontine nucleus (PPN) in isolated REM sleep behavior disorder (iRBD) and REM sleep without atonia (RSWA) to investigate the role of PPN in dream-enacting motor behaviors in RBD. We evaluated the activity of PPN through the prepulse modulation (PPM) together with other brainstem reflexes to investigate the differences in changes at brainstem. Methods We included nine patients with isolated RSWA and 10 patients with iRBD. For diagnosis, all patients underwent polysomnography. None of the patients had parkinsonism or dementia. We also included 17 healthy participants with similar age and sex. Blink reflex (BR), PPM of BR, recovery excitability of BR, and auditory startle reflex (ASR) were recorded in all participants. Results There was a prepulse inhibition deficit in iRBD and RSWA groups compared to healthy subjects. The BR-R2 recovery at 200 ms interval was also higher in patients with iRBD and RSWA. In ASR recordings, the response probabilities were higher in the RBD group compared to RSWA and control groups. Conclusion The PPM was abnormal in both iRBD and RSWA whereas ASR was enhanced in iRBD. We suggest that there are certain similarities and differences in the pathophysiologies of iRBD and RSWA.

Purpose Evidence shows that low-level laser therapy (LLLT) may shorten the recovery time of healing wounds. This study sought to assess the effect of LLLT on the recovery time of neurosensory deficits after Le Fort I osteotomy and bilateral sagittal split osteotomy using the blink reflex. Methods This randomized double-blind clinical trial evaluated 12 patients undergoing orthognathic surgery of the maxilla/mandible. One random quadrant of the maxilla/mandible underwent 810 nm gallium-aluminum-arsenide laser (infrared spectrum, 200 mW, 12 J/cm2, 60-second irradiation time of each point, continuous-wave mode), while the laser handpiece was used in off mode for the other quadrant, postoperatively. The patients underwent LLLT at 1, 5, 10, and 14 days, postoperatively. The blink test was performed to assess the function of the trigeminal nerve, and the 2-point discrimination (TPD) test was performed to assess the recovery of the inferior alveolar nerve (IAN) and the infraorbital nerves at 30 and 90 days, postoperatively. Data were analyzed using the Mann-Whitney U test (alpha = 0.05). Results Six women and 6 men were evaluated (mean age = 23.41 ± 5.03 years). Both groups showed significant improvement in function of the IAN and infraorbital nerves, postoperatively in blink reflex test (P Conclusions LLLT with 810-nm diode laser can accelerate the recovery from paresthesia after orthognathic surgery. The blink reflex can be used as a quantitative index for neurosensory assessment in line with subjective clinical tests such as the TPD test.

Occipital nerve stimulation (ONS) is a specific form of peripheral neuromodulation used in the treatment of chronic pain disorders. A particular field of application is in the therapy of treatment-refractory headaches, especially of chronic migraine. The precise mode of action is unknown. It is presumed that central and peripheral sensitization are reduced in patients with chronic headache. The aim of this study was to examine the effect of ONS on pain-modulatory mechanisms in the trigeminocervical area in patients with chronic migraine. In a balanced repeated measurements design in eight patients with chronic migraine with and without active ONS, we analyzed which effects ONS had on the orbicularis oculi reflex dynamically elicited by corneal air flow. The orbicularis oculi reflex in active ONS (7.38 ± 20.14 eyelid closures/minute) compared to inactive ONS (18.73 ± 14.30 eyelid closures/minute) is significantly reduced (p = 0.021). The results show that under active ONS compared to inactive ONS in patients with chronic migraine, the orbicularis oculi reflex, dynamically triggered by a standardized air flow, is significantly reduced. This suggests that ONS is able to directly counteract the trigeminally mediated central sensitization in chronic migraine and protectively reduce the effects of aversive peripheral stimulation.

Multiple electrophysiologic studies have been conducted in the evaluation of facial neuropathy. In our study, the diagnostic and prognostic values of nerve conduction studies (NCSs) and transcranial magnetic stimulation (TMS) were compared for idiopathic unilateral facial neuropathy. We recruited patients with newly diagnosed idiopathic unilateral facial neuropathy and performed a blink reflex test, facial NCSs, and TMS. The amplitude of facial compound muscle action potential (CMAP) and motor evoked potential (MEP) between the affected and unaffected sides of the face was compared. A total of 30 patients were enrolled in the final analysis. TMS yielded a better detection rate, and MEP reduction rate was significantly higher than CMAP reduction rate, early in the course of the disease. Poor prognosis was positively associated with the CMAP reduction rate. The cutoff value of the CMAP reduction rate in the prediction of poor prognosis was established as 0.42. Facial TMS could detect idiopathic unilateral facial neuropathy with a high sensitivity when used as an early diagnostic tool. Facial NCS could predict prognosis, and the CMAP reduction rate was significantly associated with poor short-term prognosis.

The excitability of brainstem circuitries mediating defensive blinking in response to abrupt sensory inputs is continuously modulated by cortical areas, e.g., the hand-blink reflex (HBR), elicited by intense electrical median nerve stimulation, is enhanced when the stimulated hand is close to the face, with the behavioural purpose to optimize self-protection from increased threat. Here we investigated whether such cortically mediated HBR facilitation can be influenced by prepulse inhibition (PPI), which is known to occur entirely at the subcortical level. Twenty healthy volunteers underwent HBR recordings in five experimental conditions. In conditions 1 and 2, the stimulated hand was held either near (1) or far (2) from the face, respectively. In conditions 3 and 4, stimulation of the hand near the face was preceded by a peri-liminal prepulse to the index finger of the contralateral hand held either near (3) or far from the face (4). In condition 5, participants self-triggered the stimulus eliciting the HBR. We observed a reproducible HBR in 14 out of 20 participants and measured onset latency and area of the HBR in orbicularis oculi muscles bilaterally. HBR area decreased and latency increased in condition 2 relative to condition 1; HBR area decreased and latency increased markedly in condition 3, and somewhat less in condition 4, relative to conditions 1 and 2; self-stimulation (condition 5) also suppressed HBRs, but less than prepulses. These findings indicate that PPI of the HBR is more robust than the cognitive modulation exerted by top-down cortical projections. Possibly, an attentional shift to a prepulse may serve to reduce blinking in response to perturbation when it is convenient, in a given situation, not to interrupt ongoing visual processing.

Background Neurophysiological markers in dystonia have so far not been sistematically applied in clinical practice due to limited reproducibility of results and low correlations with clinical findings. Exceptions might be represented by the blink reflex (BR), including its recovery cycle (BRRC) and the trigemino-cervical reflex (TCR) which, compared to other neurophysiological methods, have shown more consistent alterations in cervical dystonia (CD). However, a comparison between the two techniques, and their possible correlation with disease symptoms, have not been thoroughly investigated. Objectives To assess the role of BR, BRCC and TCR in the pathophysiology of idiopathic cervical dystonia. Methods Fourteen patients and 14 age-matched healthy controls (HC) were recruited. Neurophysiological outcome measures included latency of R1 and R2 components of the BR, R2 amplitude, BRRC, latency and amplitude of P19/N31 complex of TCR. Clinical and demographic features of patients were also collected, including age at disease onset, disease duration, presence of tremor, sensory trick and pain. The Toronto Western Spasmodic Torticollis Rating Scale was used to characterize dystonia. Results Compared to HC, CD patients showed increased latency of the BR R2 and decreased suppression of the BRRC. They also showed increased latency of the P19 and decreased amplitude of P19/N31 complex of TCR. The latency of P19 component of TCR was positively correlated with disease duration. Conclusions We propose that the increased latency of R2 and P19 observed here might be reflective of brainstem dysfunction, mediated either by local interneuronal excitability changes or by subtle structural damage.

MFS has been reported to recur in 10-12% of patients. There may be a genetic component related to HLA-DR2. Anti-GAD antibodies can be present in MFS along with anti-GQ1b. Common EMG/NCS associations consist of a predominantly axonal, sensory polyneuropathy and absent H reflexes. A 32-year-old female with a history of hypothyroidism presented to our institution twice with symptoms of diplopia, lower extremity weakness and distal paresthesias occurring a year apart. She had ophthalmoplegia, reduced reflexes, and ataxia on exam. CSF showed a borderline elevated protein of 47 and white blood cells

To test the reliability and accuracy of the 2Win Refractometer Corneal Reflexes App (CR App) in detecting manifest strabismus in pediatric patients. Prospective study involving 167 children with suspected strabismus (mean age 7.6 years; SD = 3.0, range 2–14 years) undergoing the CR App ocular alignment assessment (Pediatric Ophthalmologist) versus the alternate cover test with prism ocular alignment assessment for distance (Orthoptist) as the gold standard. The AAPOS 2013 guidelines for the detection of manifest strabismus in primary position (> 8 PD) were used. Total sensitivity, specificity, PPV, and NPV for the CR App were 79.2%, 86.2%, 86.4%, and 78.9%, respectively. The overall inconclusive rate was 17.9%, but was 36.3% in children younger than 5. Sensitivity and PPV for vertical deviations were poor (33.3% and 12.5%, respectively). The accuracy of the CR App regarding the degree (in prism diopters) of manifest deviations was tested with the Wilcoxon signed rank sum test: correlation with the gold standard was good for esodeviations (p value = 0.765, not statistically significant) and poorer for exodeviations (p value = 0.056, still not statistically significant), whereas a significant difference (p value = 0.0001) was observed for vertical deviations. The CR App showed good sensitivity, specificity, PPV, and NPV for manifest strabismus > 8PD in accordance with the AAPOS 2013 guidelines; sensitivity and PPV were poor for vertical deviations. The accuracy of the CR App was good for horizontal deviations, but poor for vertical deviations. The inconclusive result rate was high in younger children.

Background The purpose of this study was to evaluate the functional outcomes of a modified technique of double rectangle pattern for correction of severe ptosis. Methods This is a retrospective study over a period of 8 years including patients who underwent correction of ptosis by double rectangle using autologous fascia lata sling. Surgical outcomes were assessed postoperatively by distance from the corneal light reflex to the upper eyelid margin (MRD1) and levator function. Results Twenty-six eyelids were operated in 20 patients. There were 9 males and 11 females, with age ranging from 4 to 35 years. Preoperatively, all patients had poor MRD1 and poor levator function. Postoperative MRD1 was good in 13 patients (17 eyelids), fair in 5 (7eyelids), and poor in 2 patients (2 eyelids). Postoperative levator function was excellent in 12 patients (15 eyelids), good in 6 (9 eyelids), and fair in 2 patients (2 eyelids). At a mean follow-up of 12 months, adequate correction was achieved in 24 eyelids, and 2 eyelids had undercorrection. Conclusion Frontalis sling with a double rectangle is simple and more efficient, as it provides a straight line of pull to the eyelid for correction of severe ptosis.

Objective: The magnitude of hand blink reflex (HBR) increases when a threatening stimulus is positioned in the peripersonal space (PPS) compared with stimulus in the extrapersonal space (EPS). We hypothesized that the reflex increase in PPS might change depending on whether the stimulus was seen. We aimed to investigate the alterations in HBR response to understand the effects of vision on cortical modulation of HBR. Methods: The HBR was recorded from 11 healthy volunteers while the hand was far away from the face (EPS), close to the face with eyes open (PPS-eyes open), and close to the face with eyes closed (PPS-eyes closed). Changes in the response magnitudes were compared between the three conditions. Results: HBR was obtained in all subjects. As expected, there was an increase in the reflex magnitude in the PPS-eyes open condition relative to EPS. In the PPS-eyes closed condition, the duration and latency were shorter and the area under the curve was significantly smaller compared with the PPS-eyes open condition. Conclusion: The enhancement of HBR in PPS is attributed to tonic top-down modulation. Our study provides evidence for the special sensory modulation of the PPS effect on HBR and may suggest cortical modulation of top-down modulation of brainstem neural circuits.

Introduction: This study aimed to investigate the possible excitability changes in the trigeminovascular system based on blink reflex (BR) in patients experiencing migraine and to compare migraine aura attacks and attack-free period. Materials and Methods: A total of 56 patients diagnosed with migraine headache with aura and 20 healthy individuals without migraine were evaluated electrophysiologically using the BR test. The BR test was repeated twice in patients with migraines during attacks with aura and attack-free period. Results: During the migraine attack with aura, R1 latencies were shorter, and R2 latencies were longer than in the interictal period. Likewise, R1 latencies were shorter, and R2 latencies were longer, in the interictal period compared to normal values obtained in the control group. Conclusion: The detected BR abnormalities have been thought to be able to reflect migraine-related dysfunction in the brainstem and trigeminovascular connections. Significance: It has been concluded that the detected BR abnormalities might reflect migraine-related dysfunction in the brainstem and trigeminovascular connections, indicating increased neuronal excitability in migraine.

A literature review was performed on the use of electrodiagnostic (EDX) tests including nerve conduction study, electromyography, exteroceptive reflex, blink reflex, and late response in the evaluation of patients with stiff person syndrome (SPS). A web survey was conducted to report the extent of EDX testing usage in the evaluation of SPS among laboratories accredited by the American Academy of Neuromuscular and Electrodiagnostic Medicine. Coactivation of selected agonist and antagonist muscles was performed in 5 healthy subjects to determine its specificity for SPS. Observation of continuous motor unit activity on electromyography and elicitation of exteroceptive reflexes by electric stimulation are informative in assisting a diagnosis of SPS, but further studies focusing on their sensitivities in diagnosing SPS and specificities in differentiating SPS from other movement disorders are needed. The value of EDX testing in SPS lies in ruling out other neuromuscular disorders.

Spontaneous blink rate is considered a biomarker of central dopaminergic activity. Recent evidence suggests that the central dopaminergic system plays a role in nociception. In the present study, we aimed to investigate whether pain modulates spontaneous blink rate in healthy subjects. We enrolled 15 participants. Spontaneous blink rate was quantified with an optoelectronic system before and after: (1) a painful laser stimulation, and (2) an acoustic startling stimulation. In control experiments, we investigated whether laser stimulation effects depended on stimulation intensity and whether laser stimulation induced any changes in the blink reflex recovery cycle. Finally, we investigated any relationship between spontaneous blink rate modification and pain modulation effect during the cold pressor test. Laser, but not acoustic, stimulation increased spontaneous blink rate. This effect was independent of stimulation intensity and negatively correlated with pain perception. No changes in trigeminal-facial reflex circuit excitability were elicited by laser stimulation. The cold pressor test also induced an increased spontaneous blink rate. Our study provides evidence on the role of dopamine in nociception and suggests that dopaminergic activity may be involved in pain modulation. These findings lay the groundwork for further investigations in patients with pathological conditions characterized by dopaminergic deficit and pain.

Background Infraorbital nerve dysfunction is commonly reported after zygomaticomaxillary complex fractures. We evaluated sensory changes in four designated areas (eyelid, nose, zygoma, and lip) innervated by the infraorbital nerve. This evaluation was conducted using the static two-point discrimination test and the vibration threshold test. We assessed the diagnostic significance of the blink reflex in patients with infraorbital nerve dysfunction. Methods This study included 18 patients, all of whom complained of some degree of infraorbital nerve dysfunction preoperatively. A visual analog scale, the infraorbital blink reflex, static two-point discrimination, and the vibration threshold were assessed preoperatively, at 1 month postoperatively (T1), and at a final follow-up that took place at least 4 months postoperatively (T4). The results were analyzed using a multilevel generalized linear mixed model. Results Scores on the visual analog scale significantly improved at T1 and T4. The infraorbital blink reflex significantly improved at T4. Visual analog scale scores improved more rapidly than the infraorbital blink reflex. Two-point discrimination significantly improved in all areas at T4, and the vibration perception threshold significantly improved in the eyelid at T4. Conclusions Recovery of the infraorbital blink reflex reflected the recovery of infraorbital nerve dysfunction. We also determined that the lip tended to recover later than the other areas innervated by the infraorbital nerve.

Objective To characterize the frequency and patterns of optic, trigeminal, and facial nerve involvement by neuroimaging and electrophysiology in IgG4 anti‐neurofascin 155 antibody‐positive (NF155+) chronic inflammatory demyelinating polyneuropathy (CIDP). Methods Thirteen IgG4 NF155+ CIDP patients with mean onset age of 34 years (11 men) were subjected to neurological examination, blink reflex, and visual‐evoked potential (VEP) testing, and axial and/or coronal T2‐weighted head magnetic resonance imaging (MRI). Results Among 13 patients, facial sensory impairment, facial weakness, and apparent visual impairment were observed in three (23.1%), two (15.4%), and two (15.4%) patients, respectively. All 12 patients tested had blink reflex abnormalities: absent and/or delayed R1 in 11 (91.7%), and absent and/or delayed R2 in 10 (83.3%). R1 latencies had strong positive correlations with serum anti‐NF155 antibody levels (r = 0.9, P ≤ 0.0001 on both sides) and distal and F wave latencies of the median and ulnar nerves. Absent and/or prolonged VEPs were observed in 10/13 (76.9%) patients and 17/26 (65.4%) eyes. On MRI, hypertrophy, and high signal intensity of trigeminal nerves were detected in 9/13 (69.2%) and 10/13 (76.9%) patients, respectively, whereas optic nerves were normal in all patients. The intra‐orbital trigeminal nerve width on coronal sections showed a significant positive correlation with disease duration. Interpretation Subclinical demyelination frequently occurs in the optic, trigeminal, and facial nerves in IgG4 NF155+ CIDP, suggesting that both central and peripheral myelin structures of the cranial nerves are involved in this condition, whereas nerve hypertrophy only develops in myelinated peripheral nerve fibers.

Background Bell’s palsy (BP) is a common idiopathic cranial mononeuropathy. The electrophysiological tests are one of supportive tools for localizing the site of facial nerve lesion, and to determine the severity and prognosis of the injury. The aim of this study was to evaluate the role of electrophysiology in the prediction of outcome of patients with Bell’s palsy. This study was carried out on 30 adult patients with Bell’s palsy. All study subjects were assessed clinically by Sunnybrook facial nerve grading score (SBS) and electrophysiologically by electroneurography (ENoG), blink reflex (BR), and electromyography (EMG); first evaluation was within 7th to10th day from onset, the second evaluation was done at 20th day, and the follow-up visit was after 1 month to assess the clinical grading system (SBS). Results At 1 month, 20 patients (66.7%) had good recovery, while 10 patients (33.3%) had poor recovery according to the Sunnybrook scale. Multiple logistic regression analysis showed that the most significant predictive indicator of BP recovery was ENoG value and R1 latency of BR test. The receiver operating characteristic (ROC) curves showed ENoG degeneration index of 74.6%, considered as a critical cutoff value of non-recovery, with the sensitivity 95% and specificity 90%, and the highest specificity was with blink reflex parameters (R1, R2 latency) 100%. Conclusion BR and ENoG were the best predictors of non-recovery of facial function, while EMG findings did not add any prognostic significance. The combination of both tests BR and ENoG, along with clinical findings can be considered a good indication in the acute phase of BP for the possibility to develop palsy residua.

Introduction: Transcranial electrical (TES) and magnetic stimulation (TMS) are both used for assessment of the motor function of the spinal cord in horses. Muscular motor evoked potentials (mMEP) were compared intra-individually for both techniques in five healthy horses. mMEPs were measured twice at increasing stimulation intensity steps over the extensor carpi radialis (ECR), tibialis cranialis (TC), and caninus muscles. Significance was set at p < 0.05. To support the hypothesis that both techniques induce extracranially elicited mMEPs, literature was also reviewed.Results: Both techniques show the presence of late mMEPs below the transcranial threshold appearing as extracranially elicited startle responses. The occurrence of these late mMEPs is especially important for interpretation of TMS tracings when coil misalignment can have an additional influence. Mean transcranial motor latency times (MLT; synaptic delays included) and conduction velocities (CV) of the ECR and TC were significantly different between both techniques: respectively, 4.2 and 5.5 ms (MLT TMS --MLT TES ), and -7.7 and -9.9 m/s (CV TMS -CV TES ). TMS and TES show intensity-dependent latency decreases of, respectively, -2.6 (ECR) and -2.7 ms (TC)/30% magnetic intensity and -2.6 (ECR) and -3.2 (TC) ms/30V. When compared to TMS, TES shows the lowest coefficients of variation and highest reproducibility and accuracy for MLTs. This is ascribed to the fact that TES activates a lower number of cascaded interneurons, allows for multipulse stimulation, has an absence of coil repositioning errors, and has less sensitivity for varying degrees of background muscle tonus. Real axonal conduction times and conduction velocities are most closely approximated by TES.Conclusion: Both intracranial and extracranial mMEPs inevitably carry characteristics of brainstem reflexes. To avoid false interpretations, transcranial mMEPs can be identified by a stepwise latency shortening of 15-20 ms when exceeding the transcranial motor threshold at increasing stimulation intensities. A ring block around the vertex is advised to reduce interference by extracranial mMEPs. mMEPs reflect the functional integrity of the route along the brainstem nuclei, extrapyramidal motor tracts, propriospinal neurons, and motoneurons. The corticospinal tract appears subordinate in horses. TMS and TES are interchangeable for assessing the functional integrity of motor functions of the spinal cord. However, TES reveals significantly shorter MLTs, higher conduction velocities, and better reproducibility.

Purpose: To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3–5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods: PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013–April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results: Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2–5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion: In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169), SCOPUS: re.j, info:eu-repo/semantics/published

Objective To investigate the prognostic and predictive value of intraoperative blink reflex (BR) monitoring during microvascular decompression (MVD) for hemifacial spasm (HFS). Methods We retrospectively reviewed 41 patients with HFS undergoing MVD with intraoperative BR and lateral spread response (LSR) monitoring. Facial spasm was evaluated for six months postoperatively. Results The BR resolved in 38 patients and persisted in three after MVD. For patients who exhibited BR resolution, 1-day, 1-month, and 6-month follow-ups revealed that 35 (92.1%), 35 (92.1%), and 38 (100%) patients had spasm resolution, respectively. However, of the three patients with persistent BR, one (33.3%), one (33.3%), and zero (0%) patients exhibited spasm resolution at the three corresponding follow-ups. We found a statistically significant difference in spasm resolution between the persistent and resolved BR groups at six months postoperatively. A comparison between intraoperative BR and LSR monitoring revealed that BR was a better predictor of clinical outcomes. Conclusions Intraoperative BR monitoring is a potentially useful tool to help facilitate an adequate decompression and is a reliable prognostic predictor of surgical outcome. Significance This study is the first to document the relationship between intraoperative BR monitoring and surgical outcome in patients with HFS.

To compare the visual and refractive outcomes between centration on the corneal vertex and the pupil center in corneal refractive surgery. A comprehensive literature search was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane Library to identify relevant studies. The primary outcomes were the postoperative spherical equivalent (SE), effectiveness [uncorrected distance visual acuity (UDVA) ≥ 20/20, eyes within ± 0.50 diopter (D) of target refraction], and safety [loss ≥ 2 lines of corrected distance visual acuity (CDVA)]. Higher-order aberrations were considered secondary outcomes. Seven studies describing a total of 1964 eyes were included in this meta-analysis. A statistical significance in postoperative SE was found between the two centration methods for the correction of myopia that favor the CV-centered method (p

A previous study reported thermal effects resulting from millimeter wave exposures at 35 and 94 GHz on non-human primates, specifically rhesus monkeys' (Macaca mulatta) corneas, but the data exhibited large variations in the observed temperatures and uncertainties in the millimeter wave dosimetry. By incorporating improvements in models and dosimetry, a non-human primate experiment was conducted involving corneal exposures that agreed well with a three-layer, one-dimensional, thermodynamic model to predict the expected surface temperature rise. The new data indicated that the originally reported safety margins for eye exposures were underestimated by 41 ± 20% over the power densities explored. As a result, the expected minimal visible lesion thresholds should be raised to 10.6 ± 1.5 and 7.1 ± 1.0 J cm at 35 and 94 GHz, respectively, provided that the power density is less than 6 W cm for subjects that are unable to blink. If the blink reflex was active, a power density threshold of 20 W cm could be used to protect the eye, although the eyelid could be burned if the exposure was long enough.

Purpose To investigate whether impaired lacrimal pump function is a possible cause of discharge in patients wearing an artificial eye compared with the remaining healthy eye. Methods Consecutive patients wearing unilateral ocular prosthesis for ≥6 months were included in this retrospective study. Excluded were any deformities of eyelids or nasal passage, socket complications such as entropion, ectropion, ptosis, infection, pyogenic granuloma, contracted socket, obstruction of nasolacrimal duct diagnosed with lacrimal irrigation and a difference greater than 2 mm in terms of protrusion between two eyes detected by Hertel exophthalmometry. Patients were asked to score the levels of tearing and mucopurulent discharge between 0 and 5 to assess lacrimal drainage function subjectively. Furthermore, dacryoscintigraphy was performed to assess the functional status of the lacrimal system objectively. Results Included were 32 subjects (12 females, 20 males; aged 32.94 ± 17.62, range 13-78). Mean duration of prosthetic wearing 26.41 ± 21.30 (6-72) months. The mean subjective scores of tearing and mucopurulent discharge were 1.56 ± 1.67 and 1.94 ± 1.63, respectively. The rate of functional stenosis was significantly higher in the anophthalmic socket side as compared to the healthy side (P = 0.002). The rates of a presac, preduct, and intraduct obstruction was notes as n = 9, n = 10, n = 1 and n = 0, n = 6, n = 2 in the anophthalmic side and the companion eye, respectively (P = 0.021). Conclusion Compared to paired healthy eyes, the ocular prosthesis exhibited significantly higher rates of functional lacrimal duct obstruction, especially at the presac level. The alterations in orbital volume and tear film composition in addition to reduced corneal reflex blinking may lead to the failure of lacrimal pump function in artificial eyes.

Purpose To investigate and provide objective documentation of the possible differences in the axonal reinnervation process of facial muscles after hypoglossal-facial nerve anastomosis. Then, to search for the presence of the trigemino-hypoglossal reflex and determine whether it indicates better peripheral recovery. Methods Electrophysiological examination performed on 20 patients who had undergone VII-XII anastomosis, with follow-up periods of more than 2 years. Results The mean follow-up time after surgery was 4.1 +/- 1.3 years (range 2-8 years). The degrees of axonal reinnervation for the orbicularis oculi (OOc) and orbicularis oris (OOr) were 46.91 +/- 19.77 and 32.65 +/- 14.85, respectively. And the difference between these muscles was statistically significant (p = 0.018) in favor of the OOc. In addition, R1 blink reflexes that were not followed by R2 components were observed in 30% of the patients. However, these 6 patients with short-latency potential did not differ from the others in terms of latency, the amplitude of compound muscle action potential (CMAP), and degree of axonal reinnervation (p > 0.05) at both muscles (OOc and OOr). Conclusion The recoveries of the lower face and upper face are different after VII-XII anastomosis, and in our patients the OOc healed better. In addition, R1 blink reflexes that were not followed by R2 components were observed in 30% of the patients. However, the patients with these blink reflexes did not have better peripheral healing in their neuromuscular units, which suggests that the blink reflex is not an indicator for peripheral recovery.

Objectives: The “nociceptive-specific” blink reflex (nBR) evoked by extraoral stimulation has been used to assess trigeminal nociceptive processing in patients with trigeminal nerve damage regardless of the site of damage. This study aimed to test the feasibility of nBR elicited by intraoral stimulation, compare intraoral and extraoral nBR and assess the intrarater and interrater reliability of the intraoral nBR for the maxillary (V2) and mandibular (V3) branches of the trigeminal nerve. Materials and methods: In 17 healthy participants, nBR was elicited by stimulation of two extraoral and two intraoral sites by two operators and repeated intraorally by one operator. Main outcome variables were intraoral stimulus-evoked pain scores and nBR R2 responses at different stimulus intensities. Intraclass correlation coefficients (ICC) were used to assess reliability. Results: Dependent on the stimulus intensity, intraoral stimulation evoked R2 responses in up to 12/17 (70.6%) participants for V2 and up to 8/17 (47.1%) participants for V3. Pain scores (p

Electrophysiological studies can provide objective and quantifiable assessments of movement disorders. They are useful in the diagnosis of hyperkinetic movement disorders, particularly tremors and myoclonus. The most commonly used measures are surface electromyography (sEMG), electroencephalography (EEG) and accelerometry. Frequency and coherence analyses of sEMG signals may reveal the nature of tremors and the source of the tremors. The effects of voluntary tapping, ballistic movements and weighting of the limbs can help to distinguish between organic and functional tremors. The presence of Bereitschafts-potentials and beta-band desynchronization recorded by EEG before movement onset provide strong evidence for functional movement disorders. EMG burst durations, distributions and muscle recruitment orders may identify and classify myoclonus to cortical, subcortical or spinal origins and help in the diagnosis of functional myoclonus. Organic and functional cervical dystonia can potentially be distinguished by EMG power spectral analysis. Several reflex circuits, such as the long latency reflex, blink reflex and startle reflex, can be elicited with different types of external stimuli and are useful in the assessment of myoclonus, excessive startle and stiff person syndrome. However, limitations of the tests should be recognized, and the results should be interpreted together with clinical observations.

The corneal reflex assesses the integrity of the trigeminal and facial cranial nerves. This brainstem reflex is fundamental in neuroprognostication after cardiac arrest and in brain death determination. We sought to investigate corneal reflex testing methods among neurologists and general critical care providers in the context of neuroprognostication following cardiac arrest. This is an international cross-sectional study disseminated to members of the Neurocritical Care Society, Society of Critical Care Medicine, and American Academy of Neurology. We utilized an open Web-based survey (Qualtrics®, Provo, UT, USA) to disseminate 26 questions regarding neuroprognostication practices following cardiac arrest, in which 3 questions pertained to corneal reflex testing. Descriptive statistical measures were used, and subgroup analyses performed between neurologists and non-neurologists. Questions were not mandatory; therefore, the percentages were relative to the number of respondents for each question. There were 959 respondents in total. Physicians comprised 85.1% of practitioners (762 out of 895), of which 55% (419) identified themselves as non-neurologists and 45% (343) as neurologists. Among physicians, 85.9% (608 out of 708) deemed corneal reflex relevant for prognostication following cardiac arrest (neurologists 84.4% versus non-neurologists 87.0%). A variety of techniques were employed for corneal reflex testing, the most common being “light cotton touch” (59.2%), followed by “cotton-tipped applicator with pressure” (23.9%), “saline or water squirt” (15.9%), and “puff of air” (1.0%). There were no significant differences in the methods for testing between neurologists and non-neurologists (p = 0.52). The location of stimulus application was variable, and 26.1% of physicians (148/567) apply the stimulus on the temporal conjunctiva rather than on the cornea itself. Corneal reflex testing remains a cornerstone of the coma exam and is commonly used in neuroprognostication of unconscious cardiac arrest survivors and in brain death determination. A wide variability of techniques is noted among practitioners, including some that may provide suboptimal stimulation of corneal nerve endings. Imprecise testing in this setting may lead to inaccuracies in critical settings, which carries significant consequences such as guiding decisions of care limitations, misdiagnosis of brain death, and loss of public trust.

Background The Rebion blinq binocular birefringent ocular alignment screener was recently commercially released, but it did not yet have validation by American Association for Pediatric Ophthalmology and Strabismus (AAPOS) uniform guidelines. Methods Children and adults from a high-risk eye practice had screening by blinq with validation by AAPOS 2003 guidelines. Then, the blinq was compared to the Adaptica 2WIN with CR corneal reflex strabismus estimation by AAPOS 2003 guidelines plus additional efforts to identify patients with diminished binocularity. Results Blinq in 100 patients compared to 2003 AAPOS amblyopia risk factors (ARF) had sensitivity 67%, specificity 75% and PPV of 82%. Both blinq and 2WIN were completed by 87 patients median age 6.5 years. Sensitivity, specificity and positive predictive value (PPV) for blinq were 75%, 68% and 81% whereas 2WIN had 91%, 68% and 84%. The blinq referred two young patients with isolated, small-angle strabismic amblyopia that 2WIN refractive function passed. Conclusion Despite its non-refractive design to identify binocular foveation, blinq performed well with refractive and strabismic uniform risk factors and a PPV greater than 80%. Clinical trials registry NCT04195711.

Studies showed a relatively prolonged blink R1 latency in patients with diabetic distal symmetrical polyneuropathy (DSPN) compared to that without DSPN. We tested the hypothesis that blink R1 latency would provide a diagnostic alternative to nerve conduction studies (NCS) in DSPN and act as a marker of the severity of NCS abnormalities in DSPN.A total of 109 patients with type 2 diabetes underwent blink reflex studies and NCS. We used the composite amplitude scores of nerve conductions (CAS), which consisted of motor (tibial, peroneal and ulnar) and sensory (sural and ulnar) amplitudes for estimating the severity of NCS.Patients with DSPN had longer blink R1, R2, and contralateral R2 latencies (P 0.0001, P = 0.001, and P = 0.031, respectively) and higher CAS (P 0.0001). Area under curve on receiver operating characteristic curve analysis in diagnosing occurrence of DSPN in blink R1 latency was 0.772 (P 0.0001). Multiple linear regression analysis showed that blink R1 latency was independently associated with CAS.Blink R1 latency may be valuable in auxiliary diagnosis and in determining the severity of NCS abnormalities in DSPN.Blink R1 latency can be added as a supplemental marker of severity of NCS in DSPN, especially if the patient's sural amplitudes has a floor effect.

Background: The R2 component of blink reflex recovery cycle (R2BRrc) is a simple neurophysiological tool to detect the brainstem hyperexcitability commonly occurring in several neurological diseases such as Parkinson's disease and atypical parkinsonisms. In our study, we investigated for the first time the usefulness of R2BRrc to assess brainstem excitability in patients with idiopathic Normal Pressure Hydrocephalus (iNPH) in comparison with healthy subjects. Methods: Eighteen iNPH patients and 25 age-matched control subjects were enrolled. R2BRrc was bilaterally evaluated at interstimulus intervals (ISIs) of 100, 150, 200, 300, 400, 500 and 750 ms in all participants. We investigated the diagnostic performance of R2BRrc in differentiating iNPH patients from control subjects using ROC analysis. Midbrain area and Magnetic Resonance Hydrocephalic Index (MRHI), an MRI biomarker for the diagnosis of iNPH, were measured on T1-weighted MR images, and correlations between R2BRrc values and MRI measurements were investigated. Results: Fourteen (78%) of 18 iNPH patients showed an enhanced R2BRrc at ISIs 100-150-200 ms, while no control subjects had abnormal R2BRrc. The mean amplitude of bilateral R2BRrc at the shortest ISIs (100-150-200 ms) showed high accuracy in differentiating iNPH patients from controls (AUC = 0.89). R2BRrc values significantly correlated with midbrain area and MRHI values. Conclusions: This study represents the first evidence of brainstem hyperexcitability in iNPH patients. Given its low cost and wide availability, R2BRrc could be a useful tool for selecting elderly subjects with mild gait and urinary dysfunction who should undergo an extensive diagnostic workup for the diagnosis of NPH.

Glabellar tap or reflex (GR) is an old bedside clinical test used in the diagnostics of Parkinson’s disease (PD), but its diagnostic value is unclear. This study examines the diagnostic validity and reliability of GR in PD in relation to brain dopaminergic activity. GR was performed on 161 patients with PD, 47 patients with essential tremor (ET) and 40 healthy controls immediately prior to dopamine transporter (DAT) [123I]FP-CIT SPECT scanning. The binding ratios were investigated with consideration of the GR result (normal/abnormal). In addition, the consistency of the GR was investigated with 89 patients after a mean follow-up of 2.2 years. PD and ET patients had higher GR scores than healthy controls (p p = 0.09). There were no differences in the ratio of abnormal to normal GRs between the PD and ET groups (73% vs. 64% abnormal, respectively, p = 0.13) or in DAT binding between PD patients with abnormal and normal GRs (p > 0.36). Over follow-up, the GR changed from abnormal to normal in 20% of PD patients despite the presence of clinically typical disease. The sensitivity and specificity of GR for differentiating PD from ET were 78.3% and 36.2%, respectively. Although GR has been used by clinicians in the diagnostics of PD, it does not separate PD from ET. It also shows considerable inconsistency over time, and abnormal GR has no relationship with dopamine loss. Its usefulness should be tested for other clinical diagnostic purposes.

Background Superficial eye disorders are one of the most common complications of improper eye care in intensive care units that can lead to corneal ulcers and permanent eye damage. The aim of this study was to determine the effect of the implementation of eye care protocol on the incidence of infection and superficial eye disorders in patients admitted to intensive care units. Methods This study was a cross-over clinical trial that was performed on 32 patients admitted to the intensive care unit with reduced or no blink reflex following loss of consciousness or receiving sedatives. The eye of the test group received eye care according to the protocol and the eye of the control group received the routine care of the ward. The data collection form included demographic and clinical information and the clinical score scale of superficial eye disorders, which were completed in 7 days for both eyes. Data analysis was performed by McNemar and Cochran tests with a 95 % confidence interval. Results In the study of superficial eye disorders, the frequency of dacryorrhea and hyperemia was not significantly different in the second to seventh days in the control and test eyes (P P P = 0.0001). Also, the frequency of corneal opacity was not significantly different in the second and third days (P P P = 0.0001). Conclusions Based on the results, although the implementation of eye care protocol has been able to have a significant effect on reducing ocular complications and problems, routine eye care in the intensive care unit also has clinical effectiveness. Therefore, in order to prevent and completely eliminate eye disorders in the intensive care unit, more evidence and research are needed. Trial registration The trial was retrospectively registered on https://en.irct.ir/trial/43493 on 13 November 2019 (13.11.2019) with registration number [IRCT20140307016870N5].

Background Despite advances in resuscitation care, mortality rates following cardiac arrest (CA) remain high. Between one-quarter (in-hospital CA) and two-thirds (out of hospital CA) of patients admitted comatose to intensive care die of neurological injury. Neuroprognostication determines an informed and timely withdrawal of life sustaining treatment (WLST), sparing the patient unnecessary suffering, alleviating family distress and allowing a more utilitarian use of resources. The latest Resuscitation Council UK (2015) guidance on post-resuscitation care provides the current multi-modal neuroprognostication strategy to predict neurological outcome. Its modalities include neurological examination, neurophysiological tests, biomarkers and radiology. Despite each of the current strategy’s predictive modalities exhibiting limitations, meta-analyses show that three, namely PLR (pupillary light reflex), CR (corneal reflex) and N20 SSEP (somatosensory-evoked potential), accurately predict poor neurological outcome with low false positive rates. However, the quality of evidence is low, reducing confidence in the strategy’s results. While infrared pupillometry (IRP) is not currently used as a prognostication modality, it can provide a quantitative and objective measure of pupillary size and PLR, giving a definitive view of the second and third cranial nerve activity, a predictor of neurological outcome. Methods The proposed study will test the hypothesis, “in those patients who remain comatose following return of spontaneous circulation (ROSC) after CA, IRP can be used early to help predict poor neurological outcome”. A comprehensive review of the evidence using a PRISMA-P (2015) compliant methodology will be underpinned by systematic searching of electronic databases and the two authors selecting and screening eligible studies using the Cochrane data extraction and assessment template. Randomised controlled trials and retrospective and prospective studies will be included, and the quality and strength of evidence will be assessed using the Grading of Recommendation, Assessment and Evaluation (GRADE) approach. Discussion IRP requires rudimentary skill and is objective and repeatable. As a clinical prognostication modality, it may be utilised early, when the strategy’s other modalities are not recommended. Corroboration in the evidence would promote early use of IRP and a reduction in ICU bed days. Systematic review registration PROSPERO CRD42018118180

IntroductionElevated temporal discrimination thresholds (TDT) have been found in cervical dystonia (CD) and unaffected first-degree relatives, indicating autosomal dominant inheritance with reduced penetrance, serving as an endophenotype and being indicative of abnormal inhibitory processing within the brainstem-basal ganglia circuits. The blink reflex R2 recovery cycle (BRRC) is also a measure of excitability of brainstem-basal ganglia circuits, and inconsistent findings are reported in CD. The aim was to investigate TDT and BRRC in CD and evaluate its reliability as an endophenotype.Methods29 patients with isolated cervical dystonia (mean age: 56.1 ± 14.3, female n = 18) and 29 age- and gender-matched healthy controls (mean age: 56.0 ± 14.2, female n = 18) were evaluated using a TDT-paradigm, performed as previously described by testing visual, tactile and visual-tactile temporal discrimination thresholds, and the BRRC, investigated with electrical and air puff stimulation.ResultsMean visual-tactile (p = 0.001) and visual TDTs (p = 0.015) differed between CD and controls; tactile TDTs revealed no group differences (p = 0.232). No between group differences were found for BRRC using either electrical or air puff stimulation (p = 0.117). There was no correlation between the elevation of TDTs and the degree of BRRC-inhibition in CD.ConclusionOur findings support the hypothesis that the TDT is an endophenotype in CD. BRRC testing did not demonstrate disinhibition of brainstem-basal ganglia circuits in CD. In contrast to TDT, the BRRC seems not to represent an endophenotype in cervical dystonia.

Blinking is one of the motor acts performed more frequently by healthy human subjects. It involves the reciprocal action of at least two muscles: the orbicularis oculi shows a brief phasic activation while the levator palpebrae shows transient inhibition. In clinical practice, noninvasive recording of the orbicularis oculi activity is sufficient to obtain useful information for electrodiagnostic testing. Blinking can be spontaneous, voluntary, or reflex. Although the analysis of spontaneous blinks can already furnish interesting data, most studies are based on reflex blinking. This article is a review of some of the alterations that can be observed in blinking, focusing in four patterns of abnormality that can be distinguished in the blink reflex: (1) afferent versus efferent, which allows characterization of trigeminal or facial lesions; (2) peripheral versus central, which distinguishes alterations in nerve conduction from those involving synaptic delay; (3) upper versus lower brainstem lesions, which indicates the lesions involving specific circuits for trigeminal and somatosensory blink reflexes; and (4) asymmetric abnormal excitability pattern, which shows a unilateral alteration in the descending control of excitability in brainstem circuits. The blink reflex excitability recovery curve to paired stimuli may provide information about other modulatory inputs to trigemino-facial circuits, such as those proposed for the connection between basal ganglia and trigeminal neurons. Finally, prepulse inhibition of blink reflex reflects the motor surrogate of subcortical gating on sensory volleys, which is still another window by which electrodiagnosis can document motor control mechanisms and their abnormalities in neurologic diseases.

Orofacial pain syndromes encompass several clinically defined and classified entities. The focus here is on the role of clinical neurophysiologic and psychophysical tests in the diagnosis, differential diagnosis, and pathophysiological mechanisms of definite trigeminal neuropathic pain and other chronic orofacial pain conditions (excluding headache and temporomandibular disorders). The International Classification of Headache Disorders 2018 classifies these facial pain disorders under the heading Painful cranial neuropathies and other facial pains. In addition to unambiguous painful posttraumatic or postherpetic trigeminal neuropathies, burning mouth syndrome, persistent idiopathic facial and dental pain, and trigeminal neuralgia have also been identified with neurophysiologic and quantitative sensory testing to involve the nervous system. Despite normal clinical examination, these all include clusters of patients with evidence for either peripheral or central nervous system pathology compatible with the subclinical end of a continuum of trigeminal neuropathic pain conditions. Useful tests in the diagnostic process include electroneuromyography with specific needle, neurography techniques for the inferior alveolar and infraorbital nerves, brain stem reflex recordings (blink reflex with stimulation of the supraorbital, infraorbital, mental, and lingual nerves; jaw jerk; masseter silent period), evoked potential recordings, and quantitative sensory testing. Habituation of the blink reflex and evoked potential responses to repeated stimuli evaluate top-down inhibition, and navigated transcranial magnetic stimulation allows the mapping of reorganization within the motor cortex in chronic neuropathic pain. With systematic use of neurophysiologic and quantitative sensory testing, many of the current ambiguities in the diagnosis, classification, and understanding of chronic orofacial syndromes can be clarified for clinical practice and future research.

The effect of Jendrassik Maneuver (JM) has been extensively studied on monosynaptic reflexes in numerous muscles below the level at which the maneuver was performed. Here we hypothesize that the effect of JM could be observed also on other reflexes, indicating a widespread influence of performing a motor act such as the JM. We examined polysynaptic reflexes caudal (i.e., the withdrawal reflex of the lower extremities) and rostral (i.e., the blink reflex to supraorbital nerve stimulation) to the level of JM contraction. We have assessed soleus tendon (T) reflex; withdrawal reflex in tibialis anterior and soleus muscle; blink reflex (BR), blink reflex excitability recovery curve (BR-ER) and prepulse inhibition of the blink reflex. Our results showed that (1) T-reflex amplitude increased during JM and decreased just after and 15 min after JM; (2) no change in the withdrawal reflex; (3) R2 area of BR reduced significantly just after or 15 min after JM; (4) Prepulse inhibition in BR reduced significantly during JM; (5) no change in BR-ER. Our results indicate that JM leads to generalized effects on neural excitability at both caudal and rostral levels. Furthermore, JM has a selective effect on excitability of reflex circuitries.

Facial onset sensory and motor neuronopathy should be considered in the differential diagnosis of facial sensory disturbances, unilateral or bilateral, especially when blink reflex is pathologic. Because bulbar and lower motor neuron dysfunction may appear years after the facial sensory onset, long follow-up is recommended in suspected patients.

The aim of the study was to evaluate whether there was a problem in the interneuronal junctions of patients with central sleep apnea using the blink reflex test. Twenty-one (21) patients with central type apneas and/or hipopneas and 21 controls were recruited. The blink reflex test was performed and R1, R2 and contralateral R2 (R3) wave values of both groups were recorded in milliseconds (ms). The results of blink test in patients with central sleep apnea were right side R1 = 9.45 ± 4.35 ms, R2 = 33.35 ± 9.97 ms, R3 = 32.15 ± 10.05 ms and left side R1 = 9.90 ± 3.82 ms, R2 = 31.5 ± 10.5 ms, R3 = 29.00 ± 4.77 ms, (p = 0.49, p = 0.69, p = 0.60, respectively), whereas the results of blink test in controls were right side R1 = 9.25 ± 3.50 ms, R2 = 32.75 ± 11.4 ms, R3 = 32.50 ± 13.12 ms and left side R1 = 7.35 ± 2.6 ms, R2 = 27.75 ± 9.75 ms, R3 = 26.65 ± 14.5 ms. (p = 0.015, p = 0.04, p = 0.035, respectively). All left side (R1, R2, R3) blink reflex of the patients with central sleep apnea was statistically significant prolonged than controls. However, there was no statistically significant difference between women with central sleep apnea and controls regarding all right side (R1, R2, R3) blink reflex. There was statistically significant difference in R1, R2 and R3 waves of left sides blink reflex between two groups. The results may be related to central nervous system damage or/and degeneration in the interneuronal junctions of the brain stem in patients with central sleep apnea syndrome.

Background: The degree of distress caused by the sequelae of peripheral facial nerve palsy usually depends on the severity of synkinesis.Objective: To clarify whether electroneurography (ENoG) can ...

Herpes stromal keratitis (HSK) is a chronic immunoinflammatory condition which develops in response to recurrent herpes simplex virus-1 (HSV-1) infection of the cornea. Patients with HSK often demonstrate the concurrence of corneal desiccation and the loss of blink reflex. However, the relationship between severity of HSK, level of basal tears and inflammation of the lacrimal gland is mostly unexplored. In this study, we compared these variables in extraorbital lacrimal gland (EoLG) after corneal HSV-1 infection in the C57BL/6J mouse model. Our results showed a significant reduction in the volume of tears in infected eyes during the development of HSK. Extensive architectural damage to EoLG, presumably caused by a massive influx of interferon-gamma secreting T cells, was observed during clinical disease period of HSK. A positive correlation between the decrease in tear volume, severity of HSK and the damage to EoLG were evident in infected mice. The presence of infectious virus measured in EoLG during pre-clinical, but not clinical disease period of HSK, suggested that viral cytopathic effects are not the major contributors of extensive damage seen in EoLG. Furthermore, topical administration of lacritin peptide delayed but did not prevent the decrease in tears in HSV-1 infected mice, and had no significant effect in either reducing the severity of HSK or T cell infiltration in EoLG of infected mice. Together, our results showed an interplay between the severity of HSK, inflammation of EoLG, and the reduced level of tears after corneal HSV-1 infection.

Purpose To compare the effect of etomidate versus propofol infusion on hemodynamic profiles, spontaneous breathing, and corneal reflex during the induction of anesthesia. Methods Adult patients (n=80) were randomized to receive etomidate (Group E, n=40) or propofol (Group P, n=40) infusion during anesthesia induction. Throughout induction, mean blood pressure and heart rate were monitored. Time to loss of consciousness (LOC), bispectral index (BIS), existence of spontaneous breathing, and corneal reflex at LOC were recorded. Results Fewer changes in hemodynamic profile occurred in Group E compared with Group P during induction of anesthesia. The mean time to LOC was shorter with etomidate than propofol (129.5 s vs 189.5 s, P Conclusion Compared with propofol infusion, etomidate infusion during anesthesia induction had fewer effects on the hemodynamic profile of patients. Among patients who received etomidate, the BIS value was lower at LOC, and more patients displayed spontaneous breathing and corneal reflex. Trial registry number China Clinical Research Information Service, ChiCTR-IOR-17011050.

PParry–Romberg syndrome, also known as progressive hemifacial atrophy, is a rare clinical entity of unknown origin with atrophy of skin and subcutaneous fat changes. A classic case of Parry–Romberg syndrome in a woman age 43 is presented. Initial facial changes appeared at the age of 20 years amid complete well-being and in the next 21 years a subcutaneous fat atrophy of the left half face developed, resulting in characteristic deformity changes. No other complaints and manifestations of the disease (epileptic seizures, headache, involvement of the other half of the face and/or extremities) were present at the timeof survey. The analysis of blink reflex, galvanic skin reflex, needle electromyography of the m. orbicularis oris from two sides, computed tomography of the skull bones revealed no pathological changes. The face infrared thermography confirmed asymmetric reduction of temperature on the ipsilateral side. Magnetic resonance scan showed hypotrophy of the left masticatory muscle, the left submandibular salivary gland, thinning of subcutaneous fat layer, changes in the white matter of the brain. Despite the typical clinical features the Parry - Romberg syndrome is a diagnostic challenge known and it is necessary to inform doctors about the latest achievements in the study of etiology, management and prognosis of the disorder.