Background: This study examined the impact of age-adjusted cerebrospinal fluid (CSF) protein levels on clinical characteristics, disease severity, and outcomes in Guillain–Barré Syndrome (GBS) patients. Methods: This retrospective study included 71 GBS patients at UTMB Galveston. Albuminocytologic dissociation (ACD) was defined as CSF–total protein (CSF-TP) >0.45 g/L with a cell count of 0.45 g/L) and age-adjusted upper limits (URLs) for CSF-TP levels, comparing clinical, CSF, and electrophysiological characteristics across groups. Results: The mean age was 50 years (SD = 14.5). The mean age of patients with a CSF-TP > 45 g/L was higher (53 vs. 39 years, p = 0.000), whereas no such difference was noted using age-dependent URLs. Using age-adjusted CSF-TP URLs reduced the sensitivity for detecting ACD by 20%. CSF-TP > age-adjusted URLs were associated with lower MRC sum scores (39 vs. 47.43, p = 0.000), higher ICU admission rates (34% vs. 20%, p = 0.003), and the need for second-line treatment (41% vs. 17%, p = 0.049), and the trends were not observed with the conventional cutoff of 0.45 g/L. CSF-TP was an independent predictor of lower MRC sum scores (p = 0.009, 95% CI −0.058, −0.009) and higher GBS disability scores (p = 0.015, 95% CI 0.000, 0.004). Conclusions: ACD is a common finding in GBS, but normal protein levels do not exclude the diagnosis. Using age-adjusted URLs might improve specificity but reduce sensitivity for ACD detection, potentially increasing false negatives. CSF-TP levels exceeding age-adjusted URLs were more strongly associated with greater disease severity and poorer outcomes compared to the conventional cutoff of 0.45 g/L.

Rapid Resolution of Delayed Facial Palsy in Miller Fisher Syndrome With Steroid Therapy

Cerebral venous sinus thrombosis (CVST) is an uncommon type of venous thromboembolism whose diagnosis is often difficult due to its vague and non-specific clinical findings. Sometimes, the diagnosis is delayed as the symptoms were considered to be attributable to the underlying etiology, especially in patients with brain tumors such as high-grade glioma (HGG). We described the case of a 60-year-old male patient who presented with headache, generalized seizures, and right hemiparesis soon after receiving brain radiation and temozolomide therapy for HGG of the left thalamus. Initially, his symptoms were considered to be due to his underlying tumor but the subsequent imaging revealed left transverse, left sigmoid, and superior sagittal sinus thrombosis with venous hemorrhagic infarct of the left occipitoparietal lobe. The patient was started on anticoagulant therapy and symptoms resolved completely within a month. Clinicians should always consider CVST in the differential diagnosis of non-specific neurological symptoms, especially in patients with underlying brain tumors.

Germinomas involving non-midline structures such as thalamus and basal ganglia are relatively uncommon contributing up to 5–10% of all intracranial germ cell tumors. Here, we describe a case of thalamic germinoma in a 16-year-old boy who presented with recurrent episodes of headache and blurry vision for 2 months. Magnetic resonance imaging revealed heterogenous mass in the left thalamus with contrast enhancement causing mass effect and obstructive hydrocephalus. Total excision of the tumor was done by suboccipital craniotomy. Histopathology showed poorly differentiated round cells with vacuolated cytoplasm, round nuclei with prominent nucleoli which were separated by thin fibrovascular stroma infiltrated by lymphocytes. Immunohistochemistry showed diffuse immunoreactivity for placental alkaline phosphatase and octamer-binding transcription factor 3/4, and negative for glial fibrillary acidic protein, cluster of differentiation (CD)-45, and CD-30, confirming it to be a pure germinoma. With a combined approach of surgery, chemotherapy, and radiotherapy, these patients have better long-term survival rates.

Vitamin B12 deficiency can cause subacute combined degeneration (SACD) by disrupting myelin synthesis, leading to spinal cord degeneration. We present a unique case of SACD featuring symmetrical pseudoathetosis characterized by involuntary, slow, and writhing movements resulting from proprioceptive sensory impairment, which disrupts the brain’s ability to accurately perceive limb position and movement and pulmonary embolism due to elevated homocysteine levels. A 34‐year‐old male presented with chest pain, generalized weakness, and numbness in his hands and feet. Two months prior, he experienced sharp chest pain, followed by progressive numbness and weakness in his upper and lower extremities. Neurological examination revealed no nuchal stiffness, normal cranial nerve function, and impaired light touch and vibration sensation in the lower extremities. Tremulousness in the hands and feet, suggestive of pseudoathetosis, had been present for 6 months. Laboratory tests confirmed severe vitamin B12 deficiency (< 159 pg/mL), elevated homocysteine, and pancytopenia. MRI of the spine showed hyperintense signals consistent with SACD, and a chest CT revealed a large saddle pulmonary embolus. Pernicious anemia was confirmed as the cause of vitamin B12 deficiency. The patient was treated with intravenous vitamin B12, leading to significant neurological improvement. This case is the first documented instance of SACD presenting with symmetrical pseudoathetosis in all four extremities. Recognizing this rare clinical sign is essential, as it can guide early diagnosis and treatment. In addition, hyperhomocysteinemia associated with vitamin B12 deficiency is a significant risk factor for thromboembolism, underscoring the need for screening in patients with unexplained thrombotic events.