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Background and purpose: The objective was to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on European clinical autonomic practice. Methods: Eighty-four neurology-driven or interdisciplinary autonomic centers in 22 European countries were invited to fill in a web-based survey between September and November 2021. Results: Forty-six centers completed the survey (55%). During the first pandemic year, the number of performed tilt-table tests, autonomic outpatient and inpatient visits decreased respectively by 50%, 45% and 53%, and every third center reported major adverse events due to postponed examinations or visits. The most frequent newly diagnosed or worsened cardiovascular autonomic disorders after COVID-19 infection included postural orthostatic tachycardia syndrome, orthostatic hypotension and recurrent vasovagal syncope, deemed to be likely related to the infection by ≥50% of the responders. Forty-seven percent of the responders also reported about people with new onset of orthostatic intolerance but negative tilt-table findings, and 16% about people with psychogenic pseudosyncope after COVID-19. Most patients were treated non-pharmacologically and symptomatic recovery at follow-up was observed in ≥45% of cases. By contrast, low frequencies of newly diagnosed cardiovascular autonomic disorders following COVID-19 vaccination were reported, most frequently postural orthostatic tachycardia syndrome and recurrent vasovagal syncope, and most of the responders judged a causal association unlikely. Non-pharmacological measures were the preferred treatment choice, with 50%–100% recovery rates at follow-up. Conclusions: Cardiovascular autonomic disorders may develop or worsen following a COVID-19 infection, whilst the association with COVID-19 vaccines remains controversial. Despite the severe pandemic impact on European clinical autonomic practice, a specialized diagnostic work-up was pivotal to identify non-autonomic disorders in people with post-COVID-19 orthostatic complaints.

Uvod: Cilj ovog istraživanja bio je procijeniti učinak intravenskog deksametazona u akutnom zbrinjavanju bolesnika s VN-om te ispitati ulogu VEMP-a u procjeni oštećenja vestibularnog živca u VN-u. ----- Ispitanici i metode: U istraživanje su bili uključeni bolesnici s akutnim VN-om koji su bili randomizirani u dvije skupine. Bolesnici skupine A primili su intravenski deksametazon, a bolesnici skupine B placebo. Obje skupine su primile i simptomatsku terapiju. Prije i 120 minuta nakon primanja terapije procijenjeni su slijedeći parametri: stupanj nistagmusa, Fukuda test, broj povraćanja, vizualno-analogna skala mučnine, European Evaluation of Vertigo upitnik. Svim bolesnicima koji su dali pristanak učinjen je VEMP unutar tjedan dana od javljanja u hitnu službu. ----- Rezultati: Ukupno je uključeno 100 bolesnika, 52 (52%) muškarca i 48 (48%) žena. Na temelju randomizacije deksametazon je primio 51 (51%) bolesnik (skupina A) dok ih je 49 (49%) primilo placebo (skupina B). U skupini A statistički značajno manje bolesnika imalo je nistagmus III stupnja nakon terapijske intervencije dok u skupini B ta razlika nije dostigla statističku značajnost. Također, nakon terapijske intervencije nistagmus I stupnja imalo je statistički značajno više bolesnika u obje skupine, izraženije u skupini A u odnosu na skupinu B. Nađena je statistički značajno veća razlika u rezultatima upitnika European Evaluation of Vertigo u skupini A u odnosu na skupinu B nakon terapije. U VEMP dijelu istraživanja amplitude na zahvaćenoj strani bile su statistički značajno manje u usporedbi s amplitudama na zdravoj strani. Blok provođenja u oVEMP-u statistički značajno češće bio je prisutan na strani vestibularnog oštećenja u odnosu na zdravu stranu. Točnost kojom se detektirao snižen AR za oVEMP je 71%, odnosno točno je detektirano 60 strana od ukupno 84. Od tih 60 bolesnika 41 (68%) je imao snižen AR i za cVEMP, odnosno zahvaćenost obje grane vestibularnog živca. ----- Zaključak: Intravenski deksametazon dovodi do boljeg oporavka nistagmusa u usporedbi s placebo skupinom te ima povoljan učinak na simptome VN-a izražene European Evaluation of Vertigo upitnikom. Rezultati analiza VEMP varijabli pružaju dokaze o VEMP-u kao korisnoj metodi za ispitivanje oštećenja pojedinih grana vestibularnog živca u VN-u., Background: Aim of this study was to determine the efficacy of intravenous dexamethasone in acute management of VN patients and to determine the usefulness of VEMP in assessment of vestibular nerve damage in VN. ----- Patients and methods: Patients with acute VN were included in the study and were randomised into two groups. Patients in group A received intravenous dexamethasone and patients in group B received placebo. Both groups of patients received symptomatic therapy as well. Before and 120 minutes after therapy the following parameters were recorded: degree of nystagmus, Fukuda test, number of vomiting, visual-analogue scale of nausea, European Evaluation of Vertigo questionnaire. All patients who gave consent underwent VEMP during seven days time from presentation. ----- Results: A total of 100 patients were enrolled in the study, 52 (52%) males and 48 (48%) females. 51 (51%) patients were randomized to receive dexamethasone and 49 (49%) to receive placebo. In group A statistically significant smaller number of patients had III degree nystagmus after therapy compared with group B. After therapy, significantly more patients had I degree nystagmus in both gropus, which was more pronounced in group A. There was a statistically significant greater difference in European Evaluation of Vertigo questionnaire in group A compared with group B after therapy administration. Regarding the VEMP part of the study amplitudes on the affected side were significantly smaller than amplitudes on the healthy side. Conduction block on oVEMP was significantly more often present on the affected side than on the healthy side. The accuracy of AR was 71% for oVEMP, meaning that it accurately detected 60 out of 84 affected sides. Of those 60 detected sides, 41 (68%) had lower AR for cVEMP, meaning that the inferior branch was affected as well. ----- Conclusion: Intravenous dexamethasone leads to a better recovery of nystagmus when compared to placebo and it has an ameliorating effect on symptoms as measured by European Evaluation of Vertigo questionnaire. VEMP analysis has been demonstrated to be useful for vestibular nerve damage detection in VN patients.

Coronavirus disease 2019 (COVID-19) vaccines have been reported as possible triggers of the production of antibodies pathogenic to the peripheral nerve and neuromuscular junction. We report on a patient who experienced vertical diplopia three weeks after the booster dose of the Pfizer-BioNTech vaccine (Comirnaty®). The diagnosis of myasthenia gravis (MG) was established based on highly positive antibodies to the nicotinic acetylcholine receptor (nAChR). Treatment with pyridostigmine and prednisone was started with gradually raising doses. On a follow- up exam two months after treatment initiation, clinical improvement was noted with an almost normal bulbomotor examination. The occurrence of diplopia following COVID-19 vaccination should raise suspicion of new-onset ocular MG and testing for anti-nAChR antibodies is advised.

© 2022 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes., Background and purpose: Disorders of the autonomic nervous system (ANS) are common conditions, but it is unclear whether access to ANS healthcare provision is homogeneous across European countries. The aim of this study was to identify neurology-driven or interdisciplinary clinical ANS laboratories in Europe, describe their characteristics and explore regional differences. Methods: We contacted the European national ANS and neurological societies, as well as members of our professional network, to identify clinical ANS laboratories in each country and invite them to answer a web-based survey. Results: We identified 84 laboratories in 22 countries and 46 (55%) answered the survey. All laboratories perform cardiovascular autonomic function tests, and 83% also perform sweat tests. Testing for catecholamines and autoantibodies are performed in 63% and 56% of laboratories, and epidermal nerve fiber density analysis in 63%. Each laboratory is staffed by a median of two consultants, one resident, one technician and one nurse. The median (interquartile range [IQR]) number of head-up tilt tests/laboratory/year is 105 (49-251). Reflex syncope and neurogenic orthostatic hypotension are the most frequently diagnosed cardiovascular ANS disorders. Thirty-five centers (76%) have an ANS outpatient clinic, with a median (IQR) of 200 (100-360) outpatient visits/year; 42 centers (91%) also offer inpatient care (median 20 [IQR 4-110] inpatient stays/year). Forty-one laboratories (89%) are involved in research activities. We observed a significant difference in the geographical distribution of ANS services among European regions: 11 out of 12 countries from North/West Europe have at least one ANS laboratory versus 11 out of 21 from South/East/Greater Europe (p = 0.021). Conclusions: This survey highlights disparities in the availability of healthcare services for people with ANS disorders across European countries, stressing the need for improved access to specialized care in South, East and Greater Europe.