metricas
covid
Buscar en
Medicina Clínica (English Edition)
Toda la web
Inicio Medicina Clínica (English Edition) Diffuse axonal injury associated with COVID-19 infection
Journal Information

Statistics

Follow this link to access the full text of the article

Letter to the Editor
Diffuse axonal injury associated with COVID-19 infection
Lesión axonal difusa asociada a infección por COVID-19
Alba Lopez-Fernández, Manuel Quintana-Diaz
Corresponding author
manuel.quintana@uam.es

Corresponding author.
, Manuel Sánchez-Sánchez
Hospital Universitario La Paz, Madrid, Spain
Read
2048
Times
was read the article
472
Total PDF
1576
Total HTML
Share statistics
 array:24 [
  "pii" => "S2387020620303843"
  "issn" => "23870206"
  "doi" => "10.1016/j.medcle.2020.06.005"
  "estado" => "S300"
  "fechaPublicacion" => "2020-09-25"
  "aid" => "5242"
  "copyright" => "Elsevier España, S.L.U.. All rights reserved"
  "copyrightAnyo" => "2020"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "cor"
  "cita" => "Med Clin. 2020;155:274-5"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:1 [
    "total" => 0
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0025775320303602"
      "issn" => "00257753"
      "doi" => "10.1016/j.medcli.2020.06.005"
      "estado" => "S300"
      "fechaPublicacion" => "2020-09-25"
      "aid" => "5242"
      "copyright" => "Elsevier España, S.L.U."
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "cor"
      "cita" => "Med Clin. 2020;155:274-5"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:1 [
        "total" => 0
      ]
      "es" => array:11 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>"
        "titulo" => "Lesi&#243;n axonal difusa asociada a infecci&#243;n por COVID-19"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "274"
            "paginaFinal" => "275"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Diffuse axonal injury associated with COVID-19 infection"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figura 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 702
                "Ancho" => 1250
                "Tamanyo" => 69579
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">RM cerebral en secuencias de susceptibilidad magn&#233;tica&#46; Se observan m&#250;ltiples microhemorragias que afectan tanto al compartimento supra- como infratentorial&#44; de localizaci&#243;n m&#225;s superficial en la uni&#243;n corticosubcortical y profunda&#44; con una afectaci&#243;n m&#225;s significativa del cuerpo calloso&#44; c&#225;psulas internas y comisura blanca anterior&#46; Estos hallazgos sugieren da&#241;o axonal difuso&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Alba Lopez-Fern&#225;ndez, Manuel Quintana-Diaz, Manuel S&#225;nchez-S&#225;nchez"
            "autores" => array:3 [
              0 => array:2 [
                "nombre" => "Alba"
                "apellidos" => "Lopez-Fern&#225;ndez"
              ]
              1 => array:2 [
                "nombre" => "Manuel"
                "apellidos" => "Quintana-Diaz"
              ]
              2 => array:2 [
                "nombre" => "Manuel"
                "apellidos" => "S&#225;nchez-S&#225;nchez"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2387020620303843"
          "doi" => "10.1016/j.medcle.2020.06.005"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620303843?idApp=UINPBA00004N"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775320303602?idApp=UINPBA00004N"
      "url" => "/00257753/0000015500000006/v1_202009140619/S0025775320303602/v1_202009140619/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:17 [
    "pii" => "S2387020620303715"
    "issn" => "23870206"
    "doi" => "10.1016/j.medcle.2019.06.035"
    "estado" => "S300"
    "fechaPublicacion" => "2020-09-25"
    "aid" => "4950"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "cor"
    "cita" => "Med Clin. 2020;155:275"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
      "titulo" => "Acute intoxication by acetonitrile"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:1 [
          "paginaInicial" => "275"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Intoxicaci&#243;n aguda por acetonitrilo"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Roger Malo Barres, C&#225;ndido Mu&#241;oz Mu&#241;oz, Lluis Sanchez Sitjes"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Roger"
              "apellidos" => "Malo Barres"
            ]
            1 => array:2 [
              "nombre" => "C&#225;ndido"
              "apellidos" => "Mu&#241;oz Mu&#241;oz"
            ]
            2 => array:2 [
              "nombre" => "Lluis"
              "apellidos" => "Sanchez Sitjes"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620303715?idApp=UINPBA00004N"
    "url" => "/23870206/0000015500000006/v2_202102250949/S2387020620303715/v2_202102250949/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2387020620303776"
    "issn" => "23870206"
    "doi" => "10.1016/j.medcle.2020.05.017"
    "estado" => "S300"
    "fechaPublicacion" => "2020-09-25"
    "aid" => "5233"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;"
    "documento" => "simple-article"
    "crossmark" => 0
    "subdocumento" => "cor"
    "cita" => "Med Clin. 2020;155:273"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
      "titulo" => "Pityriasis rosea Gibert type rash in an asymptomatic patient that tested positive for COVID-19"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:1 [
          "paginaInicial" => "273"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Erupci&#243;n tipo pitiriasis rosada de Gibert en una paciente asintom&#225;tica con positividad para COVID-19"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0005"
          "etiqueta" => "Fig&#46; 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1306
              "Ancho" => 1740
              "Tamanyo" => 164589
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "at0005"
              "detalle" => "Fig&#46; "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The image shows a rash consisting of 0&#46;3 to 1&#46;5&#8239;cm in diameter round and oval erythematous scaly plaques with peripheral collarette scaling&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "David Mart&#237;n Enguix, Mar&#237;a del Carmen Salazar Nievas, Divina Tatiana Mart&#237;n Romero"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "David"
              "apellidos" => "Mart&#237;n Enguix"
            ]
            1 => array:2 [
              "nombre" => "Mar&#237;a del Carmen"
              "apellidos" => "Salazar Nievas"
            ]
            2 => array:2 [
              "nombre" => "Divina Tatiana"
              "apellidos" => "Mart&#237;n Romero"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0025775320303511"
        "doi" => "10.1016/j.medcli.2020.05.024"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775320303511?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620303776?idApp=UINPBA00004N"
    "url" => "/23870206/0000015500000006/v2_202102250949/S2387020620303776/v2_202102250949/en/main.assets"
  ]
  "en" => array:15 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
    "titulo" => "Diffuse axonal injury associated with COVID-19 infection"
    "tieneTextoCompleto" => true
    "saludo" => "Dear Editor"
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "274"
        "paginaFinal" => "275"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Alba Lopez-Fern&#225;ndez, Manuel Quintana-Diaz, Manuel S&#225;nchez-S&#225;nchez"
        "autores" => array:3 [
          0 => array:2 [
            "nombre" => "Alba"
            "apellidos" => "Lopez-Fern&#225;ndez"
          ]
          1 => array:4 [
            "nombre" => "Manuel"
            "apellidos" => "Quintana-Diaz"
            "email" => array:1 [
              0 => "manuel.quintana@uam.es"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          2 => array:2 [
            "nombre" => "Manuel"
            "apellidos" => "S&#225;nchez-S&#225;nchez"
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Hospital Universitario La Paz&#44; Madrid&#44; Spain"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Lesi&#243;n axonal difusa asociada a infecci&#243;n por COVID-19"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 842
            "Ancho" => 1500
            "Tamanyo" => 82815
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Brain MRI in magnetic susceptibility sequences&#46; Multiple microbleeds can be seen that affect both the supra- and infra-tentorial compartments&#44; located more superficially at the cortical-subcortical junction and deep&#44; with more significant involvement&#44; of the corpus callosum&#44; internal capsules&#44; and anterior white commissure&#46; These findings suggest diffuse axonal injury&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diffuse axonal injury &#40;DAI&#41; is microscopic damage to the white matter of the corpus callosum and brain stem&#44; and is one of the leading causes of loss of consciousness and a vegetative state in traumatic brain injuries &#40;TBI&#41;&#46; Isolated cases of DAI have been identified in the context of hypoxia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">DAI&#39;s clinical presentation usually relates to its severity&#44; with a broad spectrum of symptoms ranging from headaches or vomiting to neurological deficits&#44; loss of consciousness&#44; or coma&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite the fact that the COVID-19 pathology is mainly respiratory and cardiovascular&#44; patients with severe SARS-CoV 2 infection are predisposed to present a neurological pathology&#44; including encephalopathy&#44; strokes and myopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Cerebral hypoxia within the context of severe pneumonia or immune mediated injury as the main mechanisms&#44; have both been described&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the case of a 35-year-old woman&#8239;&#44; who was admitted to the ICU with respiratory failure in March 2020&#44; with no known environmental epidemiology or previous infection&#46; When the emergency ambulance service arrived at the patient&#39;s home&#44; she presented oxygen saturation &#60;&#8239;50&#37;&#44; BP 80&#47;45&#8239;mmHg&#44; HR 96&#8239;bpm and GCS 3&#47;15&#46; They proceeded to orotracheal intubate her and she was transferred to our centre&#46; A SARS-CoV 2 PCR test resulted positive&#44; and a chest x-ray showed images compatible with bilateral COVID-19 pneumonia&#46; The patient&#39;s lab tests upon admission&#44; highlighted&#58; leukocytes 17&#46;48&#8239;&#215;&#8239;10<span class="elsevierStyleSup">3</span>&#47;&#956;L &#40;N 83&#46;5&#37;&#44; L 10&#46;0&#37;&#41;&#44; lymphocytes 1&#46;00&#8239;&#215;&#8239;10<span class="elsevierStyleSup">3</span>&#47;&#956;L&#44; fibrinogen 596&#8239;mg&#47;dL&#44; <span class="elsevierStyleSmallCaps">d</span>-dimer 6070&#8239;ng&#47;mL&#44; C-reactive protein 191&#8239;mg&#47;L&#44; ferritin 403&#8239;ng&#47;mL&#44; with no other significant alterations&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment was started with hydroxychloroquine&#44; azithromycin&#44; dexamethasone and low-molecular-weight heparin at therapeutic doses of 1&#46;5&#8239;mg&#47;kg&#47;day &#40;enoxaparin 60&#8239;mg&#47;12&#8239;h&#41;&#46; The patient&#39;s haemodynamic instability required haemodynamic support with vasoactive drugs for 15 days with maximum norepinephrine doses of up to 1&#8239;&#956;g&#47;kg&#47;min&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The first blood gas analysis after connection to mechanical ventilation &#40;MV&#41; showed a P&#58;F &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#41; ratio of 60&#44; so prolonged prone positioning was performed&#44; achieving a PaFi of 134&#46; Given the improvement in oxygenation&#44; it was decided not to perform any more prone-supine positioning cycles&#44; with P&#58;F ratio of 260 during the first week in supine&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">While admitted&#44; the patient required progressively decreasing haemodynamic support&#46; A percutaneous tracheostomy was performed 10 days after intubation&#44; and the sedatives&#47;analgesics was progressively withdrawn&#46; The patient presented abundant episodes of space and time disorientation&#44; and fluctuation in her level of consciousness&#44; with GCS between 12&#8722;14&#46; This led to prolonged ventilator weaning along with poor management of secretions&#46; After 23 days of MV&#44; decannulation was well tolerated&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient made good progress and was moved to a conventional ward&#46; While on the ward&#44; she continued to have a tendency to sleep and episodes of agitation&#44; which at first was attributed to probable confusional syndrome&#46; Due to the persistence of the episodes&#44; an MRI &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; was performed&#46; Multiple focal lesions were observed&#44; located at the junction of the grey-white matter in the corpus callosum&#44; plus anterior white commissure and internal capsules&#46; These findings suggested diffuse axonal injury&#46; Given the absence of trauma&#44; other etiologies were evaluated&#44; bearing in mind the published cases of severe patients in a situation of respiratory distress&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient&#39;s respiratory condition progressively improved&#44; while a marked decrease in processing speed with impaired attention and executive functions persisted&#46; She was allowed home after 10 days in the internal medicine ward&#44; with a scheduled visit for follow-up by neurology&#44; in the cognitive impairment consultancy&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The definitive diagnosis of diffuse axonal injury is established by autopsy&#59; however&#44; there are MRI findings suggestive of this entity&#44; such as microbleeds in the cortical-subcortical part of the convexity&#44; in the posterior part of the corpus callosum&#44; and the lateral part of the mid brain&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">After reviewing the patient&#39;s history&#44; and given that aside from traumatic brain injury&#44; hypoxia is a possible aetiology of diffuse axonal injury&#44; we are able to conclude that the data found in our patient support the diagnosis of diffuse axonal injury in the context of hypoxaemia and acute respiratory distress due to infection by SARS-CoV-2&#46; So far&#44; cases of intraparenchymal haemorrhage have been reported in patients with no comorbidity other than COVID-19 infection&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> as have brain lesions with ring contrast enhancement&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> but to our knowledge&#44; no cases have yet been described that demonstrate a correlation between COVID-19 and diffuse axonal injury&#46;</p></span>"
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lopez-Fern&#225;ndez A&#44; Quintana-Diaz M&#44; S&#225;nchez-S&#225;nchez M&#46; Lesi&#243;n axonal difusa asociada a infecci&#243;n por COVID-19&#46; Med Clin &#40;Barc&#41;&#46; 2020&#59;155&#58;274&#8211;275&#46;</p>"
      ]
    ]
    "multimedia" => array:1 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 842
            "Ancho" => 1500
            "Tamanyo" => 82815
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Brain MRI in magnetic susceptibility sequences&#46; Multiple microbleeds can be seen that affect both the supra- and infra-tentorial compartments&#44; located more superficially at the cortical-subcortical junction and deep&#44; with more significant involvement&#44; of the corpus callosum&#44; internal capsules&#44; and anterior white commissure&#46; These findings suggest diffuse axonal injury&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:5 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global hypoxia per se is an unusual cause of axonal injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Dolinak"
                            1 => "C&#46; Smith"
                            2 => "D&#46;I&#46; Graham"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s004010000218"
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Neuropathol"
                        "fecha" => "2000"
                        "volumen" => "100"
                        "paginaInicial" => "553"
                        "paginaFinal" => "560"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11045678"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan&#44; China&#46; &#91;published online ahead of print&#44; 2020 Apr 10&#93;&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "L&#46; Mao"
                            1 => "H&#46; Jin"
                            2 => "M&#46; Wang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jamaneurol.2020.1127"
                      "Revista" => array:3 [
                        "tituloSerie" => "JAMA Neurol"
                        "fecha" => "2020"
                        "paginaInicial" => "e201127"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Neurological manifestations and complications of COVID-19&#58; A literature review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "I&#46; Ahmad"
                            1 => "F&#46;A&#46; Rathore"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jocn.2020.05.017"
                      "Revista" => array:3 [
                        "tituloSerie" => "J Clin Neurosci&#46;"
                        "fecha" => "2020"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25890773"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID 19 and Intra cerebral hemorrhage&#58; Causative or Coincidental"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Sharifi-Razavi"
                            1 => "N&#46; Karimi"
                            2 => "N&#46; Rouhani"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.nmni.2020.100669"
                      "Revista" => array:3 [
                        "tituloSerie" => "New Microbes New Infect&#46;"
                        "fecha" => "2020"
                        "volumen" => "35"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID-19&#8211;associated Acute Hemorrhagic Necrotizing Encephalopathy&#58; CT and MRI Features&#46; &#91;published online ahead of print&#44; 2020 Mar 31&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "N&#46; Poyiadji"
                            1 => "G&#46; Shahin"
                            2 => "D&#46; Noujaim"
                            3 => "M&#46; Stone"
                            4 => "S&#46; Patel"
                            5 => "B&#46; Griffith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/radiol.2020201187"
                      "Revista" => array:3 [
                        "tituloSerie" => "Radiology"
                        "fecha" => "2020"
                        "paginaInicial" => "201187"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/23870206/0000015500000006/v2_202102250949/S2387020620303843/v2_202102250949/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "43309"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Letters to the Editor"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015500000006/v2_202102250949/S2387020620303843/v2_202102250949/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620303843?idApp=UINPBA00004N"
]
Article information
ISSN: 23870206
Original language: English
The statistics are updated each day
Year/Month Html Pdf Total
2024 November 6 0 6
2024 October 35 9 44
2024 September 40 6 46
2024 August 26 5 31
2024 July 31 13 44
2024 June 27 6 33
2024 May 31 2 33
2024 April 33 6 39
2024 March 46 8 54
2024 February 48 5 53
2024 January 49 2 51
2023 December 53 7 60
2023 November 34 5 39
2023 October 24 12 36
2023 September 16 2 18
2023 August 22 7 29
2023 July 26 3 29
2023 June 35 5 40
2023 May 58 8 66
2023 April 43 6 49
2023 March 5 4 9
2023 February 13 6 19
2023 January 22 9 31
2022 December 16 9 25
2022 November 16 6 22
2022 October 16 12 28
2022 September 25 7 32
2022 August 20 9 29
2022 July 14 19 33
2022 June 18 12 30
2022 May 17 7 24
2022 April 17 3 20
2022 March 30 10 40
2022 February 31 4 35
2022 January 30 14 44
2021 December 28 12 40
2021 November 31 17 48
2021 October 42 18 60
2021 September 38 20 58
2021 August 31 15 46
2021 July 22 5 27
2021 June 29 13 42
2021 May 39 19 58
2021 April 93 43 136
2021 March 53 8 61
2021 February 65 19 84
2021 January 47 5 52
2020 December 38 10 48
2020 November 25 8 33
2020 October 22 2 24
2020 September 0 10 10
Show all

Follow this link to access the full text of the article

es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos