Letter to Editor

Is Brain Fog a Temporary or Life-long Condition?

Afshan Niknafs

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e8

In the 1880s, German physician Georg Greiner coined the concept of “brain fog” to describe the cognitive deficits associated with delirium. The term “brain fog” has been used intermittently since then to describe sluggish cognition. It gained popularity again in the 1990s as a way to describe chronic fatigue syndrome and some autoimmune diseases. However, there are no diagnostic criteria for brain fog and it is not a medical condition.1
The term “brain fog” describes cognitive difficulties that are increasingly used colloquially. Long-term COVID-19 is characterized by persistent symptoms following a COVID-19 diagnosis that cannot be explained by any other illness. Persistent symptoms following COVID-19 are often described as “brain fog.” Brain fog syndrome, which is associated with excessive academic strain, was revived in the 1960s and was included in the DSM-IV.2
As a result of post-COVID-19 infection, residual cognitive impairment (“brain fog”) often interferes with work and daily activities.3 Recent investigations have shown that fungal co-infections significantly affect the morbidity and mortality of patients with COVID-19.


The International Clinical Neuroscience Journal; 2022 in a Glance

Meisam Akhlaghdoust, Alireza Zali

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e1

The acceptance rate in the ICNJ was 46% (rejection rate: 54%) in 2022 and the average peer review time was around three weeks. Overall, 32 papers, including 16 (50%) original articles, 8 (25%) case reports, 6 (18.75%) review articles, and 2 (6.25%) letters to the Editor were published in 2022. The most published topics in 2022 were COVID-19 (6 papers), mental health, and cancers. Most publications focused on COVID-19, as a common topic worldwide. Some of the articles were published as editorial letters.1,2 There were papers about COVID-19 and mental health1 and COVID-19 and headache.2
Six review papers were about “Upper Extremity Function After Stroke”, “Neurological Complications of COVID-19”, “Neuropathic Pain”, “Public Acceptance of the COVID-19 Vaccination”, “Consciousness in Sleep” and Molecular and Cellular Basis in Neurodegenerative Diseases”.3-8 Moreover, ICNJ presents eight rare, complex and challenging neurological and neurosurgical cases (“Fahr Syndrome and Syncope”, “Acute Hemifacial by Haemorrhagic Schwannoma”, “Multilevel Lumbar Spondylolisthesis”, “Convulsion Presentation of Parietal Meningioma”, “Coil Embolization in Pseudoaneurysm of the Supraglenoid Internal Carotid Artery”, “Physical Therapy for Erectile Dysfunction and Sensation”, “Traumatic Unilateral Basal Ganglia Haemorrhage”, and “Parenchymal Infarction After Subacute Subdural Hematoma Evacuation”).9-16 The editors and editorial board members of the journal believe that the publication of these cases can help develop good hypotheses for further studies in the future.
Sixteen published original articles present new and novel assessments, diagnostic methods, prevention, treatment, and approaches of neurological disease, and valuable epidemiological features and findings to be used worldwide.17-32
The International Clinical Neuroscience Journal is supported by Universal Scientific Education and Research Network (USERN). The goal of (ICNJ) is to continue publishing high quality and novel studies especially in areas of tissue engineering, molecular biology, personalized medicine, degenerative diseases and neuromodulation. We would like to invite all researchers from around the world to contribute to this journal. We appreciate the contributions of all the researchers and scientists who trusted the ICNJ.

Original / Research Article


Background: Arachnoid cysts are formations containing cerebrospinal fluid (CSF). They may be associated with the subarachnoid space. This feature is a factor that can affect the change in the size of arachnoid cysts over time. Hounsfield Unit (HU) value measurements provide rational numeric representation of imaging of tissues in computed tomography (CT) examinations. In this study, we aimed to define isolated or communicated arachnoid cysts, and whether arachnoid cysts communicate with the subarachnoid distance, with the HU values obtained in CT examinations.

Methods: Patients with radiological diagnosis of arachnoid cyst were identified retrospectively by examining the CT database. HU value measurements were recorded over the Picture Archiving and Communication System (PACS) in the area where the arachnoid cyst was detected. HU value measurements are a method that rationally shows the amount of radiograph absorption of tissues in CT examinations. HU value measurements were performed in cerebrospinal fluid (CSF) and arachnoid cysts, and whether arachnoid cysts had equal HU values with CSF. They were defined as homogeneous or heterogeneous by measuring HU values in different regions of arachnoid cysts.

Results: Data on 478 cases were obtained. An average of 2.82 CT scans were detected per case. A change in arachnoid cyst size was detected in 47 (9.8%) cases. In cases of arachnoid cysts of varying size, the mean HU value of arachnoid cysts was 9.32 ± 1.93 (6.43 ± 1.67 in the lateral ventricle and 7.04 ± 1.71 in the fourth ventricle). HU value of arachnoid cysts with a change in size significantly differed from CSF.

Conclusion: Arachnoid cysts with HU values equal to CSF are not real arachnoid cysts, and significant volume changes are not expected. Arachnoid cysts, which have a different HU value than CSF, may secrete a different fluid from CSF. This type of arachnoid cyst is a real cyst that can be detected in various sizes on CT examinations at different times since they are not in communication with the subarachnoid space.

Effectiveness of Gait Training Using Dynamic Bodyweight Support System on Locomotor Abilities of Ambulatory Children With Different Neural Disorders

Afsaneh Zeinalzadeh, Reza Lotfi, Hasan Barmaki, Mohammad Lotfi, Alireza Shadman, Ali Asadi, Hamid Reza Kobravi

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e14

Background: In this study, we evaluated the efficacy of dynamic bodyweight-supported training on the gait quality of children with different neural disorders.
Methods: Seventeen ambulatory children, aged 3 to 11 years, experiencing gait limitations, were selected to participate in the designed gait training program. Each child participated in 10 practice sessions held three days a week, with each training session using the dynamic body weight support system, comprising three stages, and lasting 20 minutes. Clinical assessments were conducted using four functional tests: “Five Time Sit to Stand Test (FSST)”, “Modified Time Up and Go (MTUG)”, “Time Up and Down Stairs (TUDS)”, and “Pediatric Berg Balance Scale” (BBS).
Results: Statistical tests demonstrated a significant increase in the post-values of the BBS after gait training. Notably, children with higher relative cognitive abilities showed more improvement. Additionally, there was a significant enhancement in the assigned score for the level of independence. As all participants had received conventional physical therapies for more than three years, reaching their maximum obtainable improvements with conventional training methods, the observed improvements could be attributed to the designed training protocol even without a control group.
Conclusion: Designed gait training protocol using a dynamic weight support system proved effective in enhancing balance, improving gait quality, and increasing the level of independence during performing functional tests in ambulatory children suffering from different locomotor disabilities.

EEG-Based Effective Connectivity Analysis for Attention Deficit Hyperactivity Disorder Detection Using Color-Coded Granger-Causality Images and Custom Convolutional Neural Network

Seyyed Abed Hosseini, Yeganeh Modaresnia, Farhad Abedinzadeh Torghabeh

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e12

Background: Attention deficit hyperactivity disorder (ADHD) is prevalent worldwide, affecting approximately 8-12% of children. Early detection and effective treatment of ADHD are crucial for improving academic, social, and emotional outcomes. Despite numerous studies on ADHD detection, existing models still lack accuracy distinguishing between ADHD and healthy control (HC) children.
Methods: This study introduces an innovative methodology that utilizes granger causality (GC), a well-established brain connectivity analysis technique, to reduce the required EEG electrodes. We computed GC indexes (GCI) for the entire brain and specific brain regions, known as regional GCI, across different frequency bands. Subsequently, these GCIs were transformed into color-coded images and fed into a custom-developed 11-layer convolutional neural network.
Results: The proposed model is evaluated through a five-fold cross-validation, achieving the highest accuracy of 99.80% in the gamma frequency band for the entire brain and an accuracy of 98.50% in distinguishing the theta frequency band of the right hemisphere of ADHD and HC children by only using eight electrodes.
Conclusion: The proposed framework provides a powerful automated tool for accurately classifying ADHD and HC children. The study’s outcome demonstrates that the innovative proposed methodology utilizing GCI and a custom-developed convolutional neural network can significantly improve ADHD detection accuracy, improving affected children’s overall quality of life.

Evaluation of Karnofsky Performance Scale as a Postsurgical Prognosis Criteria in Chronic Subdural Hematoma Cases: Discordance Between Clinical and Radiological Outcomes

Ziya Asan, Sercan Eroglu, Aydan Koysuren, Sezai Durmaz

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e3

Background: Chronic subdural hematoma (CSDH) may cause neurological deficits as well as adverse effects on the patient’s general health status. Although CSDH cases are diagnosed in the advanced age group with a very high rate, clinical findings may not be related only to CSDH. The aim should be related to clinical recovery rather than radiological recovery for these cases. We aimed to evaluate Karnofsky’s score as a measurement criterion of postoperative clinical outcomes in patients with CSDH.
Methods: Cases operated for the diagnosis of CSDH were defined retrospectively. The cases that had been operated with this diagnosis were identified by examining the institution database records. Karnofsky scores equivalent to clinical status were performed by examining patient files. Karnofsky scoring before the symptomatic period was determined and compared with the Karnofsky score belonging to the late postoperative period. The clinical and radiological findings of the preoperative and postoperative periods were compared. Independent samples t test was used to reveal the difference between the two groups.
Results: Data of 184 cases were evaluated. Seventy-three cases were operated on the left, 51 cases on the right, and 60 cases bilaterally with the diagnosis of CSDH. Burrhole exploration was performed in 119 cases, and a craniotomy was performed in 65 cases. Although a significant decrease in hematoma thickness was detected radiologically in cases operated with the craniotomy method, a more significant improvement was observed in Karnofsky’s score in cases operated with the burrhole method. In younger patients, improvement in Karnofsky’s score was significantly higher.
Conclusion: The main aim should be to improve clinical status rather than radiological improvement in the treatment of CSDH cases. In the surgical treatment of these cases, it is possible to encounter a high rate of complications depending on age. It is possible to evaluate the postoperative status rationally with Karnofsky scoring. According to the preoperative Karnofsky scoring, deciding on the surgical technique may help reduce complications.

Apparent Diffusion Coefficient Values and Intra-tumoral Susceptibility Signals in Meningiomas and Schwannomas: Useful Tools for Challenging Cases

Sweta Swaika, Akshara Gupta, Sourabh Agarwal

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e4

Background: We aimed to estimate the diagnostic accuracy of apparent diffusion coefficient values (ADC) and intra-tumoral susceptibility signals (ITSS) in differentiating meningiomas and schwannomas.
Methods: This retrospective study included 41 patients with 23 histopathologically proven meningiomas (20 patients with benign meningioma and 3 patients with high-grade meningioma) and 18 schwannomas. We calculated the mean ADC values and ADC ratio from ADC maps and intratumoral susceptibility signals (ITSS) in susceptibility-weighted imaging (SWI) for all patients. The quantitative variables were compared between the tumor groups using t test and the qualitative variables were compared between them using Chi-square test.
Results: In this study, the mean ADC value of meningiomas (0.86 ± 0.11×10-3 mm2/s, range 0.67-1.04) was lower than schwannomas (1.32 ± 0.16×10-3 mm2/s, range 1.10-1.65) with no overlap in the range of ADC values. The mean ADC ratio of schwannomas (2.0 ± 0.29, range 1.45- 2.58) was higher than meningiomas (1.24 ± 0.17, range 0.83-1.64) with some overlap. We found significant difference in mean ADC value and ADC ratio between meningiomas and schwannomas. The presence of intratumoral microhemorrhages (ITSS-H) in SWI was more suggestive of schwannomas and the presence of calcification was in favor of benign meningiomas. We did not find any significant difference in mean ADC value and ADC ratio between benign and high-grade meningiomas with considerable overlap in their range.
Conclusion: Additional magnetic resonance imaging findings such as ADC values and ITSS in SWI can help better pre-operative diagnosis of meningiomas and schwannomas, particularly in challenging patients.

Serum Matrix Metalloproteinase-9 Level and Previous Disease Activity in Relapsing-Remitting Multiple Sclerosis

Eman Hamdy, Ismail Ramadan, Jaidaa Mekky, Aya Abdel Galeel, Dina Gaber

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e5

Background: Matrix metalloproteinase-9 (MMP-9) is a marker of blood-brain barrier destruction, that is elevated during clinical relapses in multiple sclerosis (MS). In between relapses, MMP-9 levels decline but remain higher than the normal population. This study aimed to investigate the relation between serum MMP-9 level and disease activity in MS during relapse-free periods.
Methods: This was a retrospective study conducted on adult patients with relapsing-remitting MS (RRMS) whose last relapse was ≥ 1 month ago. Serum MMP-9 was withdrawn at the time of recruitment and correlated with parameters of disease activity.
Results: Of the 40 patients recruited, 75% were women. The mean age was 36.2 ± 8.4 years, and the mean disease duration was 7 years. Patients’ median Expanded Disability Status Scale (EDSS) was 3.5 (IQR: 2.5-5.25), the median duration since the last relapse was 3 months, and the median duration since last corticosteroid administration was 6 months. On multivariate regression analysis, there was a significant association between serum MMP-9 levels and duration since the last relapse (B: -0.004, 95% CI: -0.007- -0.002, P = 0.001) as well as duration since the last corticosteroid intake (B: -0.003, 95% CI: -0.006- -0.001, P = 0.005).
Conclusion: Serum MMP-9 levels correlated with the duration since last relapse and duration since last corticosteroids administration during relapse-free periods.

Innovative Measures of Verhulst Diagram for Emotion Recognition using Eye-Blinking Variability

Atefeh Goshvarpour, Ateke Goshvarpour

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e6

Background: The human body continuously reveals the status of several organs through biomedical signals. Over time, biomedical signal acquisition, monitoring, and analysis have captured the attention of many scientists for further prediction, diagnosis, decision-making, and recognition. Recently, building an intelligent emotion recognition system has become a challenging issue using the application of signal processing. Frequently, human emotion classification was proposed utilizing the internal body status in dealing with affective provocations. However, external states, such as eye movements, have been claimed to convey practical information about the participant’s emotions. In this study, we proposed an automatic emotion recognition scheme through the analysis of a single-modal eye-blinking variability.
Methods: Initially, the signal was transformed into a 2D space using the Verhulst diagram, a simple analysis based on the signal’s dynamics. Next, some innovative features were introduced to characterize the maps. Then, the extracted measures were inputted to the support vector machine (SVM) and k-nearest neighbor (kNN). The former classifier was evaluated with three kernel functions, including RBF, linear, and polynomial. The latter performances were examined with different values for k. Moreover, the classification results were assessed in two feature-set partitioning modes: a 5-fold and 10-fold cross-validation.
Results: The results showed a statistically significant difference between neutral/fear and neutral/sadness for all Verhulst indices. Also, the average values of these characteristics were higher for fear and sadness than those of other emotions. Our results indicated a maximum rate of 100% for the fear/neutral classification. Therefore, the suggested Verhulst-based approach was supremely talented in emotion classification and analysis using eye-blinking signals.
Conclusion: The novel biomarkers set the scene for designing a simple accurate emotion recognition system. Additionally, this experiment could fortify the territory of ocular affective computing, and open a new horizon for diagnosing or treating various emotion deficiency disorders.

The Positive Effect of Atropa belladonna on Inflammatory Cytokines in the Animal Model of Multiple Sclerosis

Hassanali Abedi, Mehdi Karimi, Najmeh Sadeghi, Hossein Kargar Jahromi, Maryam Jalali Jahromi, Afsaneh Ranjbar, Aref Bagherzadeh, Sepideh Dialameh

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e10

Background: Multiple sclerosis (MS) is a chronic autoimmune disease characterized by inflammation and demyelination of the central nervous system. Given the role of inflammation in the pathogenesis of MS and the anti-inflammatory effect of Atropa belladonna (AB), the aim of this study was to determine the effect of AB on inflammatory and anti-inflammatory factors in MOG35-55 induced experimental autoimmune encephalomyelitis (EAE).
Methods: Thirty-two purebred C57BL/6 mice, weighing (20 ± 2g) were randomly assigned to the 4 groups: control, and three experimental groups: EAE, EAE + AB100, and EAE + AB300 that after EAE induction received 0, 100, and 300 mg/kg AB daily. AB was dissolved in PBS (phosphate-buffered saline) and the volume of gavage in all groups was 100 μL. After 30 days, the mice were weighed, anesthetized with ether and blood was collected directly from the heart. Specific animal ELISA kits measured the inflammatory cytokines (IL-10, IL-17, IL-4, and TNF-α). One-way ANOVA with Duncan post hoc test was used for comparison between groups.
Results: EAE increased serum concentrations of TNF-α, IL-17, and decreased IL-10 and IL-4 compared to the control group. AB significantly decreased the mean level of TNF-α, IL-17 and increased IL-10 and IL-4 compared with EAE group. The effect of 300 mg/kg was clearly better than 100 mg/kg. There was also a significant difference between the control group and the 300 mg/kg group.
Conclusion: In the present study, AB plant extract increased serum levels of anti-inflammatory cytokines and decreased pro-inflammatory cytokines in the MS animal model.

Case Report

Autoimmune Parkinsonism: A Newer Manifestation of Contactin-Associated Protein-Like 2 Autoimmunity: A Case Report

Mohan V Sumedha Maturu, Aravind Varma Datla, Rajesh Babu Devabhaktuni, Prajwala Maturu, Deepak Sahebrao Mandwe

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e15

Contactin-associated protein-like 2 (CASPR2) antibodies are part of an expanding spectrum of disorders. Although they were initially associated with Morvan’s syndrome and peripheral nerve hyperexcitability, their clinical manifestations are more varied than previously recognized. In this report, we present a rare case of a middle-aged woman who experienced gait disturbances, sleep disturbances, behavioral changes, and postural abnormalities over a period of five months. A thorough examination revealed a Parkinsonian phenotype. Considering the timeline and symptomatology, an autoimmune work-up was conducted, which detected CASPR2 antibodies in the patient’s serum. Treatment with high-dose intravenous Methylprednisolone followed by rituximab effectively reversed her clinical manifestations without residual neurological deficits.

Difficulties in Diagnosis and Operation Associated With Lumbar Intradural Disc Herniation: A Case Report

Hieu T. Le, Hoai Dinh, Quynh H.T. Pham, Hoang D. Tran, Minh T. Nguyen

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e13

Intradural disk herniation (IDH) represents an uncommon instance of disk degeneration. The surgical treatment of IDH,
preoperative, and intraoperative diagnosis are difficult. The present case report highlights the difficult parts of diagnosis and surgery.
A 44-year-old man presented with lower back pain radiating to his right leg. A disk protruding into the ventral dural sac and
exhibiting the hawk-beak sign was discovered by MRI. The dorsal side was exposed and incised during L3/4 laminectomy, a
puncture on the ventral side was detected, and subsequently, three fragments extending into the dura sac were discovered. The
defect was corrected and completed internal fixing was done. Pathology identified it as nucleus pulposus tissue. At one-month
follow-up, he was able to walk normally. An incredibly uncommon form of disc degeneration is lumbar IDH. MRI can assist in
the diagnosis, however, surgical investigation and pathology are necessary for an accurate diagnosis.

A Cervical Nerve Root Cavernoma – Atypical Presentation With Diagnostic Dilemma

Sandeep Moolchandani, Gaurav Tyagi, Nishant Yagnick, Sumit Sinha, Veer Singh Mehta

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e2



Spinal cavernous angiomas are uncommon vascular malformations in spine accounting for 5-12% of all spinal vascular lesions. When present in intradural extra-medullary location, these usually present with radicular pain and neurological deficits due to mass effect (myelopathy). We here present an atypical presentation of cavernous angioma in a 54-year-old male with tinnitus, headache and sensorineural hearing loss. We have also reviewed 51 cases of intradural extramedullary cavernous angiomas including our case with respect to demographic and clinical profile.



Case Description


A 54-year-old male presented with tinnitus in left ear and occipital headache with neck pain and slight weakness of left-hand grip along with atrophy of thenar muscles. His PTA examination revealed mild left sensorineural earing loss. MRI of cervical spine showed T2WI heterogeneously hyperintense left intradural extramedullary lesion at C7 vertebral body level. It was avidly enhancing with contrast. Patient underwent C7 laminectomy with a midline durotomy and complete excision of the lesion under neuromonitoring with sacrifice of the C8 sensory root. His symptoms improved following the surgery.




Spinal nerve root cavernomas are extremely rare. They usually present with radicular or myelopathy symptoms due to compression. Repeated rupture or micro-bleeds can cause raised intracranial pressure features along with cranial nerve deficits. The diagnostic workup is not straight forward in these latter cases and the presence of cavernoma may be an unusual finding. The diagnosis of a cavernoma in an unusual location in the presence of cranial nerve dysfunction needs a high degree of diagnostic suspicion. Majority of these cavernomas have a nerve root origin or attachment. The optimal treatment is microsurgical en bloc resection which leads to an effective resolution of both the symptoms.

Coexistence of Cerebellopontine Angle Tumor and Frontal Convexity Meningioma at Distinct Location – A Rare Case Report and Review of Literature

Shalendra Singh, Aarthy Kumaraguru, Ankit Kumar, Munish Sood

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e7

The perioperative management of brain tumors can be significantly impacted by the presence of another intracranial tumor at a distinct location. We report a rare case of an adult who developed two primary brain tumors, a frontal convexity meningioma and a cerebellopontine angle (CPA) tumor at anatomically disparate locations. In our patient, it was unambiguously decided to address the CPA tumor first as it had led to multiple cranial nerve palsies and obstructive hydrocephalus. The relevant literature helped us better extrapolate the patient presentation and management of this disastrous presentation swiftly.

Case Series

Unexpected Outcomes for Headache Under Evaluation; A Case Series of Four Cases

Uddalok Das, Debasish Dey

International Clinical Neuroscience Journal, Vol. 10 No. 1 (2023), 15 January 2023, Page e9

Headache is a common cause of hospital visits and admissions throughout the world. Headaches may be primary or secondary; the primary one being far more common. Although the primary cases by far outnumber the secondary cases the role of the physician is to separate the benign causes from the more sinister ones. Using clinical examination and history alone this can often be a mountain-moving task. However, radiology can help as a problem-solving tool in equivocal cases. This case series highlights the role of radiological imaging in four cases of chronic headaches that were being treated empirically as primary headaches for a long time before neuroimaging revealed a secondary cause.