Absent Corneal Reflexes Research Articles

A nationwide survey of facial onset sensory and motor neuronopathy in Japan

The epidemiology and etiology of facial onset sensory and motor neuronopathy (FOSMN), a rare syndrome that initiates with facial sensory disturbances followed by bulbar symptoms, remain unknown. To estimate the prevalence of FOSMN in Japan and establish the characteristics of this disease, we conducted a nationwide epidemiological survey. In the primary survey, we received answers from 604 facilities (49.8%), leading to an estimated number of 35.8 (95% confidential interval: 21.5–50.2) FOSMN cases in Japan. The secondary survey collected detailed clinical and laboratory data from 21 cases. Decreased or absent corneal and pharyngeal reflexes were present in over 85% of the cases. Electrophysiological analyses detected blink reflex test abnormalities in 94.1% of the examined cases. Immunotherapy was administered in 81% of cases and all patients received intravenous immunoglobulin. Among them, 35.3% were judged to have temporary beneficial effects evaluated by the physicians in charge. Immunotherapy tended to be effective in the early stage of disease. The spreading pattern of motor and sensory symptoms differed between cases and the characteristics of the motor-dominant and sensory-dominant cases were distinct. Cases with motor-dominant progression appeared to mimic amyotrophic lateral sclerosis. This is the first nationwide epidemiological survey of FOSMN in Japan. The clinical course of FOSMN is highly variable and motor-dominant cases developed a more severe condition than other types of cases. Because clinical interventions tend to be effective in the early phase of the disease, an early diagnosis is desirable.

Predicting time to asystole following withdrawal of life-sustaining treatment: a systematic review.

The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.

Facial Onset Sensory and Motor Neuronopathy with Neurotrophic Keratitis: A Case Report

Facial-onset sensory and motor neuronopathy (FOSMN) is a rare, progressive neurodegenerative disorder characterized by sensory loss and motor deficits, primarily affecting the face and upper extremities. The condition begins with sensory impairments in the trigeminal nerve distribution, extending to involve the scalp, neck, upper limbs, and trunk. Symptoms include facial weakness, bulbar disturbances (dysphonia, dysarthria, dysphagia, and sialorrhea), and lower motor neuron signs (weakness, atrophy, fasciculation, and cramps) in the limbs. A hallmark of FOSMN is the diminished or absent corneal reflex, indicating trigeminal nerve involvement and leading to potential complications like neurotrophic keratitis (NK), which can cause corneal ulceration and blindness. The etiology of FOSMN remains uncertain, with theories proposing autoimmune or neurodegenerative origins. Diagnosis is challenging due to the overlap with other ocular surface disorders, necessitating careful examination and differential diagnosis. Management focuses on symptomatic relief, including eye protection to prevent corneal complications. Awareness and early detection of ocular symptoms in FOSMN are crucial for preventing severe outcomes like NK and blindness.

Non-Traumatic Coma in Children- A Review

Coma is defined as the unintentional failure of the patient to open their eyes spontaneously or in response to noise and inability to open for commands or localised painful stimuli with or without the ability to express comprehensible words or language response, whereas the Non traumatic coma is without any injury to the brain, and the Glasgow coma scale below 12. The Non traumatic coma causes due to the infections(tubercular meningitis, bacterial meningitis, encephalitis) and other metabolic conditions ,status epilepticus intracranial bleed, miscellaneous, hypoxic ischemic insults, Electrical shock, shunt dysfunction, Inborn error of metabolism. The monitoring parameters are Heart rate, Respiratory rate and pattern, Blood pressure, Temperature, coma severity using GCS, pupillary size, extra ocular movements, corneal reflex, posture, and motor pattern. The main symptoms are ataxia or weakness, isolated cranial nerve palsy, mild alteration of tone, poor pulse volume, apnea, abnormal pupillary size and reaction, dizziness, Headache, abnormal extra ocular movements absent corneal reflex. Management of non-traumatic coma patients at hospital includes Monitoring of Intracranial pressure, Maintenance of an adequate cerebral perfusion pressure, Management of persistent intracranial hypertension and Monitoring of Electroencephalographic Seizure activity. Infections are the most common cause for the non-traumatic coma in several cases. The pattern of infectious caused are CNS infections &gt; metabolic toxic exposure &gt; encephalitis &gt; Intoxication &gt; hypoxic ischemic insults &gt; Intracranial haemorrhages&gt;miscellaneous&gt;unknown cases. 40% of children are prone to Non traumatic coma per 10000 general population per year.

Postarrest Neuroprognostication: Practices and Opinions of Canadian Physicians.

Objective, evidence-based neuroprognostication of postarrest patients is crucial to avoid inappropriate withdrawal of life-sustaining therapies or prolonged, invasive, and costly therapies that could perpetuate suffering when there is no chance of an acceptable recovery. Postarrest prognostication guidelines exist; however, guideline adherence and practice variability are unknown. To investigate Canadian practices and opinions regarding assessment of neurological prognosis in postarrest patients. An anonymous electronic survey was distributed to physicians who care for adult postarrest patients. Of the 134 physicians who responded to the survey, 63% had no institutional protocols for neuroprognostication. While the use of targeted temperature management did not affect the timing of neuroprognostication, an increasing number of clinical findings suggestive of a poor prognosis affected the timing of when physicians were comfortable concluding patients had a poor prognosis. Variability existed in what factors clinicians' thought were confounders. Physicians identified bilaterally absent pupillary light reflexes (85%), bilaterally absent corneal reflexes (80%), and status myoclonus (75%) as useful in determining poor prognosis. Computed tomography, magnetic resonance imaging, and spot electroencephalography were the most useful and accessible tests. Somatosensory evoked potentials were useful, but logistically challenging. Serum biomarkers were unavailable at most centers. Most (79%) physicians agreed ≥2 definitive findings on neurologic exam, electrophysiologic tests, neuroimaging, and/or biomarkers are required to determine a poor prognosis with a high degree of certainty. Distress during the process of neuroprognostication was reported by 70% of physicians and 51% request a second opinion from an external expert. Significant variability exists in post-cardiac arrest neuroprognostication practices among Canadian physicians.

The Gomez-Lopez-Hernandez Syndrome: the contribution of two Hispanic giants of Pediatric Neurology. (P4-3.004)

<h3>Objective:</h3> Detail the history of the Gomez-Lopez-Hernandez syndrome (GLHS) which highlights the contribution of two giants of Pediatric Neurology of Hispanic Origin. <h3>Background:</h3> GLHS also known as cerebello-trigeminal dermal dysplasia, is a rare neurocutaneous condition of variable phenotype which was first described by two Hispanic renowned pediatric neurologists: Drs. Manuel Gomez and Arturo Lopez-Hernandez. GLHS is characterized by rhombencephalosynapsis, alopecia, and trigeminal anesthesia. Dr. Gomez of Spanish-Cuban origin is known for his long tenure as former head of Pediatric Neurology, Mayo Clinic, founder of the Child Neurology Society and his strong interest in the phakomatoses. His index GLHS case was of a 4.5-year-old girl with absent corneal reflexes, alopecia, delayed motor function, and bilateral facial analgesia [1979]. Gomez postulated that arrest of the neuroectoderm development resulted in the abnormal trigeminal innervation. Dr. Lopez-Hernandez is one of the fathers of Pediatric Neurology in Mexico having established the first pediatric neurology service at the National Institute of Pediatrics and later serving as its first head of the Neurology Department. In 1982 Lopez-Hernandez reported two unrelated girls with craniosynostosis, ataxia, trigeminal anesthesia and parietal alopecia associated with pons-vermis fusion. The GLHS eponym was first used in the literature in 1997. To date there are nearly 60 cases reported. The phenotype has been expanded to include short stature, craniofacial anomalies, growth hormone deficiency, hydrocephalus, and neuropsychiatric symptoms. No genetic cause has been identified. <h3>Design/Methods:</h3> Not applicable <h3>Results:</h3> Not applicable <h3>Conclusions:</h3> The specialty of Pediatric Neurology emerged during the 20^th century. During this period, many neurologists played significant roles in revolutionizing this field. The Gomez-Lopez-Hernandez syndrome serves to highlight the contributions of two notable giants of pediatric neurology of Hispanic origin, at a time when there was limited representation of minorities in the medical profession. <b>Disclosure:</b> Ms. Liang has nothing to disclose. Dr. Viereck has nothing to disclose. The institution of Dr. Liow has received research support from UCB. The institution of Dr. Liow has received research support from Livanova. The institution of Dr. Liow has received research support from Biogen. The institution of Dr. Liow has received research support from Novartis. The institution of Dr. Liow has received research support from Eisai. The institution of Dr. Liow has received research support from Engage Therapeutics. The institution of Dr. Liow has received research support from SK Lifescience. The institution of Dr. Liow has received research support from Cerevel. The institution of Dr. Liow has received research support from Xenon. The institution of Dr. Liow has received research support from NeuroDerm. The institution of Dr. Liow has received research support from Avanir. The institution of Dr. Liow has received research support from Annovis. The institution of Dr. Liow has received research support from Acadia. Enrique Carrazana has received personal compensation for serving as an employee of Neurelis. Enrique Carrazana has received personal compensation in the range of $100,000-$499,999 for serving as a Consultant for Neurelis, Alexza, Zogenix. Enrique Carrazana has received personal compensation in the range of $10,000-$49,999 for serving as an officer or member of the Board of Directors for Hawaii-Biotech, CND Life Sciences. Enrique Carrazana has stock in Neurelis, Marinus, .

Unilateral ‘Ophthalmic nerve pattern’ of sensory loss from a demyelinating lesion in lateral cervical cord: a lesson in neuroanatomy (P14-3.002)

<h3>Objective:</h3> To describe an unusual localization for ‘ophthalmic nerve pattern’ of sensory loss and to review neuro-anatomic pathways of facial sensation. <h3>Background:</h3> Isolated ophthalmic nerve sensory loss is usually due to lesions in the ophthalmic nerve. Imaging of cervical spinal cord is not undertaken in patients with this finding even though spinal trigeminal nucleus (STN), which receives fibers that convey pain, temperature and light touch from the face and mucus membranes, extends from caudal pons to third/fourth cervical spinal cord level. <h3>Design/Methods:</h3> Case report. <h3>Results:</h3> A 54-year-old female with mild multiple sclerosis (MS) on no disease-modifying therapy (DMT), developed numbness and itching on her right scalp, radiating down her upper face. Neurologic exam revealed decreased sensation to light touch and pinprick in the distribution of the right ophthalmic branch (V1) and absent right corneal reflex. Vision, other facial sensation, cranial nerves and other neurologic functions were intact. Magnetic resonance imaging (MRI) of the brain revealed old demyelinating lesions and a new Gdenhancing lesion in the right side of the upper cervical cord, corresponding to the pars caudalis portion of the spinal trigeminal nucleus. She received gabapentin for pain, which was tapered as her symptoms resolved within weeks. <h3>Conclusions:</h3> Our patient appeared to have a lesion within the ophthalmic nerve, but her deficits were due to demyelination in pars caudalis of STN in cervical spine. Localized loss of sensation in our patient is likely due to somatotopic organization of STN whereby the midline facial structures are represented rostrally and the caudal portion – laterally (‘onionskin’ pattern). Patients presenting with unexplained ophthalmic nerve pattern of sensory loss may require dedicated imaging of cervical cord. <b>Disclosure:</b> Dr. Omari has nothing to disclose. Dr. Jain has nothing to disclose. Dr. Kister has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Genentech-Roche. The institution of Dr. Kister has received research support from Genentech. Dr. Kister has received publishing royalties from a publication relating to health care.

Ophthalmic manifestation of Hereditary Sensory and Autonomic Neuropathy – Five-year follow up

Hereditary Sensory and Autonomic Neuropathy (HSAN) is a rare genetic disorder that usually begins in childhood. It is associated with sensory dysfunction (depressed reflexes, altered pain and temperature perception). We report a case of an orphan and adopted girl child with HSAN type IV masquerading as keratomalacia with normal developmental milestones, absent sensation to pain and temperature, bilateral absent corneal reflexes, corneal xerosis, anhidrosis, and trophic ulcers in both hands and feet.

A rare presentation of neurosarcoidosis as the superior orbital fissure syndrome

We are reporting a rare case of neurosarcoidosis that presented with superior orbital fissure syndrome. A 51-year-old Indian woman who suffered from 2 weeks duration, insidious onset gradually progressive left sided headache limited to forehead, left periorbital pain, diplopia on looking toward left, and numbness on the left forehead was referred to our hospital. Ophthalmic findings included left oculomotor nerve, trochlear nerve and abducens nerve palsies, absent corneal reflex, and loss of touch, pain and temperature sensation in V1 distribution. Brain and orbit magnetic resonance imaging (MRI) showed contrast enhancing area at the left orbital apex with normal optic nerve. Normal CSF analysis. High ESR, and chest x-ray showing non-homogenous patchy opacities in bilateral lung fields leaded us for neoplastic screening. Chest computed tomography (CT) revealed multiple ill-defined irregular lung parenchymal nodular opacities of varying sizes involving bilateral lungs with enlarged mediastinal and bilateral axillary lymph nodes. Elevated angiotensin converting enzyme level was found. Biopsy of the axillary lymph node showed non-caseating granulomatous lymphadenitis with giant cells containing schaumann bodies and asteroid bodies in the cytoplasm. These findings indicating an inflammatory response induced by sarcoidosis. After the initiation of steroid treatment, the patient experienced complete remission without any recurrence. When examining a case presenting with superior orbital fissure syndrome with contrast enhancing MRI lesion at the orbital apex, the additional chest CT to exclude neoplastic lesions can detect pulmonary sarcoidosis and extraneural lesions. These may avoid delays in the diagnosis and management of neurosarcoidosis.

Clinico-Etiological Profile and Predictors of Mortality of Nontraumatic Coma in Children of Upper Egypt: A Prospective Observational Study.

Nontraumatic coma (NTC) is a considerable cause of morbidity and mortality in children. This prospective observational study aimed to determine the clinico-etiological profile of NTC in children and delineate clinical signs predicting mortality in Upper Egypt from June 2019 to May 2020. All children from 1 month of age to 16 years who were admitted with NTC were included in the study. All patients received full histories and physical examinations, including Glasgow Coma Scale (GCS). Routine laboratory investigations including complete blood count, electrolytes, blood sugar, serum creatinine, and liver function tests were performed for all patients. Specific investigations such as metabolic studies, lumbar punctures, brain computed tomography scans, and magnetic resonance imaging were done when indicated. The precise etiology was determined and clinical presentations for survivors and nonsurvivors were compared. Among the 137 cases of NTC identified, central nervous system (CNS) infections were the most common cause leading to 38 cases, followed by toxic causes in 37 cases, status epilepticus in 22 cases, and metabolic causes in 21 cases. Hypothermia, hypotension, abnormal respiratory patterns, muscle hypotonia, absent corneal reflex, presence of shock, and need for mechanical ventilation were significantly correlating with mortality. The estimated mortality rate was 18.2% and all cases with GCS < 5 died. Toxic causes were the most commonly identified etiology in patients who died. In conclusion, the authors identified several etiologies for NTC in Upper Egypt and their corresponding clinical signs at presentation. This information can be used to improve the clinical care provided to children with NTC.

Ventriculitis following neuraxial block.

Dear Editor, Ventriculitis has been mostly reported following neurosurgical procedures such as external ventricular drains, ventricular shunts, trauma, immunocompromised host, intrathecal chemotherapy, or meningitis.[1-3] It is uncommon to have ventriculitis following neuraxial blockade for a non-neurosurgical procedure. The incidence of meningitis after a neuraxial block is extremely low (about 0–2 cases every 10,000 procedures).[4] To best of our knowledge, no case of ventriculitis has been reported following a neuraxial block. We report a case of a patient developing ventriculitis following a neuraxial block. A 53-year-old Indian male presented to the trauma center with circumferential degloving injury of the left lower extremity following a road traffic accident. After a primary survey the patient was taken to the operation theater for debridement and skin grafting. The procedure was done under combined neuraxial-epidural block in L4–5 intervertebral space and the epidural catheter was left in situ for postoperative analgesia. Two days later, a second debridement was done under neuraxial block in L3–4 intervertebral space. The epidural catheter was removed 2 days after this surgery. On the third postoperative day, the patient complained of a severe headache and continued to deteriorate and on the seventh day became irritable with febrile episodes. Emergent intubation was done in the ward to secure the airway and the patient was shifted to ICU. By the end of the second day in the ICU, the GCS/Glasgow coma scale deteriorated even further. Non-contrast computerized tomography of brain did not reveal any abnormalities. The patient continued to worsen clinically with absent pupillary and corneal reflexes and doll’s eye. MRI of the brain was done, which showed signs of debris in the occipital horns of both the lateral ventricle and cisterna magna suggestive of periventriculitis [Figure 1].Figure 1: Isointense-dependent contents in occipital horns of bilateral lateral ventricles and cisterna magna, likely ventriculitisThe CSF samples were collected after external ventricular drain insertion which showed Acinetobacter baumanii infection sensitive only to Colistin. Colistin was initiated, both systemic and intrathecal. By the end of the third day of colistin initiation, improvement in GCS was observed. CSF became sterile by the end of the fourth day. EVD/external ventricular drain as replaced by ommaya reservoir and intrathecal colistin administration was continued through ommaya reservoir for 4 weeks. By the end of 1 week GCS improved significantly. The patient was extubated and discharged after a 4-week course of intrathecal therapy. In the absence of the causes mentioned above we postulate that the possible source for ventriculitis could be related to the procedure of neuraxial block at the time of the second surgery as there was Acinetobacter baumanii suggesting hospital-acquired infection rather than community-acquired. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship - Nil. Conflicts of interest There are no conflicts of interest.

Pediatric Brain Death.

1. Brooke T. McLaughlin, MD, MPH* 2. James J. Filiano, MD* 1. *Dartmouth Hitchcock Medical Center, Lebanon, NH A 3-year-old boy was airlifted from a nearby hospital after a motor vehicle collision. At the scene he had a prolonged extraction and was not breathing. He was intubated and experienced cardiac arrest during transport. Cardiopulmonary resuscitation was performed, with return of circulation. On arrival at the emergency department the patient exhibited complete loss of consciousness, vocalization, and volitional and reflex activity. Computed tomographic scans consistent with global cerebral infarction and laboratory results of multiorgan failure indicated little hope for meaningful recovery. The team waited 24 hours from the time of injury and prepared to initiate the brain death examination. The family was despondent and refused to believe that the damage could be irreversible. The team called the chaplain, social worker, and primary care physician to support the family in the subsequent hours. The initial brain death examination found the child unresponsive to painful stimuli, with fixed pupils and absent light, corneal, cough, gag, and oculovestibular reflexes. An apnea test demonstrated no spontaneous respiratory effort to PaCO2 greater than 60 mm Hg. A post–24-hour examination and apnea test confirmed that the child fulfilled the criteria for brain death. The family struggled to accept the news because their child appeared alive to them: his heart was beating and his chest was rising on the mechanical ventilator. Brain death is a legal definition of death recognized in every state in the United States. It is the irreversible cessation of all function of the entire brain, including the brain stem. There is medical, legal, and social consensus that loss of this function equates to death just as definitively as irreversible cessation of circulatory and respiratory function. However, it remains a challenging issue because brain-dead patients often maintain the appearance of life while on a ventilator (or while receiving other assisted support). This …

Therapeutic management of hypovitaminosis A and zinc deficiency in a lactating cow from a small dairy herd in muranga county, Kenya

Background: Hypovitaminosis A and zinc deficiency were diagnosed in a 7-year-old Friesian cow from a small milking herd comprising of thirty Friesian cows in a zero grazing unit in Muranga County in Kenya, on Friday, November 15, 2019. The cow was weighing approximately 500 kilograms and had calved four months ago. The daily production of milk was tweny five litres. The cow had a history of sudden inappetance, reduced weight, sternal recumbency, convulsions and heavy lacrymation. Clinical examination revealed slight clouding of the cornea, and dilated pupils which did not respond to light. The menace response was almost absent but palperal and corneal reflexes were present. The cow was not apparently blind. Methods: The clinical examination of the skin revealed a fungal infection. Skin scrapings and hair from the lesions were examined for fungal species by direct microscopy in 10% KOH and lactophenol. Collected samples were inoculated on mycobiotic agar. The inoculum was incubated at 28°C for two to six weeks and examined for colony formation. Culture examination revealed Trichophyton verrucosum as the cause of dermatophytosis. Blood sample was taken from the cow into a vial containing heparin for spectrophotometric estimation of vitamin A and serum zinc concentrations. Results: Vitamin A and serum zinc concentrations were 5.12 μg/dl and 3.24 μg/L, respectively. The reference serum values for vitamin A are in the range of 15.4 to 32.3 μg/dl, while reference serum zinc levels are in the range of 6-12 μg/L for optimum physiologic functioning in dairy cattle. On the basis of history, clinical examination and significantly low serum vitamin A and zinc levels, the lactating friesian cow was diagnosed to be suffering from combined hypovitaminosis A and zinc deficiency. The dairy cow was therapeutically managed through administration of zinc sulphate orally, at a dosage rate of 1 gram per week for six weeks, administration of vitamin A at a dosage rate of 30,000 international units (IU), deep intramuscularly, once daily for seven days, and intramuscular administration of 3 mls of BelamylR, once daily for seven days. The body parts with lesions caused by T. verrucosum were treated through topical administration of zinc oxide ointment once daily for twenty one days. Following treatment of the lactating cow, significant improvement was observed in terms of disappearance of lachrymation, corneal clouding, sternal recumbency, skin lesions and convulsions. The appetite also returned to normal. All the other cows in the farm were supplemented with vitamin A and zinc. The client was also advised to include fresh napier and bermuda grass in the cattle diet, since they have been shown to contain adequate levels of beta carotene and zinc. Conclusion: In conclusion, zinc and vitamin A supplementation may be of benefit for recovery of cows from sternal recumbency and dermatophytosis.

Prognostic Value of P25/30 Cortical Somatosensory Evoked Potential Amplitude After Cardiac Arrest.

The aim of this study was to evaluate the prognostic performance of the peak amplitude of P25/30 cortical somatosensory evoked potentials in predicting nonawakening in targeted temperature management-treated cardiac arrest patients. Prospective analysis. Four academic tertiary care hospitals. Eighty-seven cardiac arrest survivors after targeted temperature management. Analysis of the amplitude of P25/30. In all participants, somatosensory evoked potentials were recorded after rewarming, and bilaterally absent pupillary and corneal reflexes were evaluated at 72 hours after the return of spontaneous circulation. We analyzed the amplitudes of the N20 and P25/30 peaks and the N20-P25/30 complex in cortical somatosensory evoked potentials. Upon hospital discharge, 87 patients were dichotomized into the awakening and nonawakening groups. The lowest amplitudes of N20, P25/30, and N20-P25/30 in the awakening patients were 0.17, 0.45, and 0.73 μV, respectively, and these thresholds showed a sensitivity of 70.5% (95% CI, 54.8-83.2%), 86.4% (95% CI, 72.7-94.8%), and 75.0% (95% CI, 59.7-86.8%), respectively, for nonawakening. The area under the curve of the P25/30 amplitude was significantly higher than that of the N20 amplitude (0.955 [95% CI, 0.912-0.998] vs 0.894 [95% CI, 0.819-0.969]; p = 0.036) and was comparable with that of the N20-P25/30 amplitude (0.931 [95% CI, 0.873-0.989]). Additionally, adding resuscitation variables or an absent brainstem reflex to the P25/30 amplitude showed a trend toward improving prognostic performance compared with the use of other somatosensory evoked potential amplitudes (area under the curve, 0.958; 95% CI, 0.917-0.999 and area under the curve, 0.974; 95% CI, 0.914-0.996, respectively). Our results provide evidence that the absence of the P25/30 peak and a reduction in the P25/30 amplitude may be considered prognostic indicators in these patients.

Trapping and Thrombectomy of Giant Thrombosed Vertebral Artery Aneurysm via Bilateral Subocciptal Approach – Technical Note

Background: Giant aneurysms arising from the vertebral artery (VA) are rare; they represent 4% to 6% of all intracranial giant aneurysm. The natural history of thrombosed aneurysms is extremely poor. Most such lesions progressively enlarge and result in irreversible progression of neurological deficits and fatal sequelae through resultant compression of the brainstem. We present the clinical experience of giant thrombosed vertebral artery aneurysm successfully treated via a bilateral suboccipital approach. A 62 –year-old woman presented with slight dysarthria and ataxia for one year. Neurological examination showed right lateral gaze nystagmus, bilateral absent corneal reflex, absent gag reflex, bilateral dysdiadochokinesia, poor right finger nose test, and slightly poor tandem gait. MRI showed a 27 mm giant thrombosed left VA aneurysm with brain stem compression. We performed trapping of the aneurysm and thrombectomy through a bilateral suboccipital approach. First, the distal portion was clipped from the left side. Next, the proximal portion was approached from the right side. Thrombectomy was performed and after shrinkage of the aneurysm, the clips were applied involving some part of the aneurysm just distal to PICA.&#x0D; Conclusion: The optimum treatment for aneurysm of this type is thought to be complete obliteration of the parent artery with trapping and thrombectomy to decompress the brainstem. Sometimes if PICA could not be preserved Occipital artery (OA)-PICA bypass should be considered.

Neuroprognostication Practices in Postcardiac Arrest Patients: An International Survey of Critical Care Providers.

To characterize approaches to neurologic outcome prediction by practitioners who assess prognosis in unconscious cardiac arrest individuals, and assess compliance to available guidelines. International cross-sectional study. We administered a web-based survey to members of Neurocritical Care Society, Society of Critical Care Medicine, and American Academy of Neurology who manage unconscious cardiac arrest patients to characterize practitioner demographics and current neuroprognostic practice patterns. Physicians that are members of aforementioned societies who care for successfully resuscitated cardiac arrest individuals. Not applicable. A total of 762 physicians from 22 countries responses were obtained. A significant proportion of respondents used absent corneal reflexes (33.5%) and absent pupillary reflexes (36.2%) at 24 hours, which is earlier than the recommended 72 hours in the standard guidelines. Certain components of the neurologic examination may be overvalued, such as absent motor response or extensor posturing, which 87% of respondents considered being very or critically important prognostic indicators. Respondents continue to rely on myoclonic status epilepticus and neuroimaging, which were favored over median nerve somatosensory evoked potentials for prognostication, although the latter has been demonstrated to have a higher predictive value. Regarding definitive recommendations based on poor neurologic prognosis, most physicians seem to wait until the postarrest timepoints proposed by current guidelines, but up to 25% use premature time windows. Neuroprognostic approaches to hypoxic-ischemic encephalopathy vary among physicians and are often not consistent with current guidelines. The overall inconsistency in approaches and deviation from evidence-based recommendations are concerning in this disease state where mortality is so integrally related to outcome prediction.

Predict cardiac death after withdrawal of life-supporting treatment in the neurocritical patients: a neurological score

Background: Accurate prediction the time of death after withdrawal of life-supporting treatment (WLST) in the neurocritical patients is important for donation after cardiac death. We aimed to establish a new neurological scoring system to predict the probability of death within 60 minutes after WLST.Methods: We retrospectively reviewed the clinical data from a cohort of 231 neurocritical patients from June 2016 to July 2018. The patients were divided into training and external validation sets. In the training set, we used univariate and multivariable logistic regression analyses to assess associations between death within 60 minutes after WLST and these variables. Points attributed to each variable were summed to create a predictive score for cardiac death. We assessed performance of the score using ROC analysis. Finally, we validated the predictive ability of the score in an external validation set.Results: Multivariable logistic regression analysis showed that absent corneal reflexes, absent cough reflexes, extensor or absent motor response and anisocoric or bilaterally dilated pupil were associated with death within 60 minutes in training set (all p&lt;0.05). The area under curve for the score was 0.839 (95% CI 0.763-0.916) for prediction of death within 60 minutes. A score of 4-6 had a sensitivity of 95.88% and a specificity of 69.05% to predict death within 60 minutes after WSLT. In external validation set, the prevalence of these predictors was similar with training sample.Conclusions: The neurological score may be useful to predict time of death after WLST in neurocritical patients.

Trigeminal trophic syndrome following anterior inferior cerebellar artery infarction

A 70-year-old woman with hypertension presented about 3 months ago with complaints of dysarthria, left lower motor neuron facial palsy with preserved Bell’s phenomenon, sensory loss over the left side...

Epidermoid cysts of the cavernous sinus: clinical features, surgical outcomes, and literature review.

Epidermoid cysts of the cavernous sinus (CS) are rare, and no large case series of these lesions has been reported. In this study, the authors retrospectively reviewed the outcomes of the surgical management of CS epidermoid cysts undertaken at their center and performed a review of any such cysts reported in the literature over the past 40 years. Clinical data were obtained on 31 patients with CS epidermoid cysts that had been surgically treated at the authors' hospital between 2001 and 2016. The patients' medical records, imaging data, and follow-up outcomes were retrospectively analyzed. The related literature from the past 40 years (18 articles, 20 patients) was also evaluated. The most common chief complaints were facial numbness or hypesthesia (64.5%), absent corneal reflex (45.2%), and abducens or oculomotor nerve deficit (35.5%). On MRI, 51.6% of the epidermoid cysts showed low T1 signals and equal or high T2 signals. In the other lesions, the radiological findings varied considerably given differences in the composition of the cysts. Surgery was performed via the extradural approach (58.1%), intradural approach (32.3%), or a combined approach (9.7%). After the operation, symptoms remained similar or improved in 90.3% of patients and new oculomotor paralysis developed after the operation in 9.7% of patients. Seven patients (22.6%) developed meningitis postoperatively (5 aseptic and 2 septic), and all of them recovered. All patients achieved good recovery before discharge (Karnofsky Performance Status score ≥ 70). Over an average follow-up of 4.6 ± 3.0 years in 25 patients (80.6%), no recurrence or reoperation occurred, regardless of whether total or subtotal resection of the capsule had been achieved. Both the extradural and intradural approaches can enable satisfactory lesion resection. A favorable prognosis and symptomatic improvement can be expected after both total and subtotal capsule resections. Total capsule resection is encouraged to minimize the possibility of recurrence provided that the resection can be safely performed.

Influence of sedation on onset and quality of euthanasia in sheep

The purpose of this study was to determine if dexmedetomidine administered IV prior to euthanasia in sheep affected the speed or quality of euthanasia. Twenty clinically healthy Dorset-cross adult ewes between 1 and 3years of age were enrolled in a randomized blinded experimental trial. The subjects were randomly assigned to receive dexmedetomidine 5μg/kg IV or an equivalent volume of saline. Five minutes later, euthanasia was accomplished with a pentobarbital/phenytoin overdose given IV. The time to apnea, asystole, cessation of audible heartbeat, and absence of corneal reflex were recorded by two blinded investigators. If any muscle spasms, contractions, vocalization, and/or dysrhythmias were noted, the time was recorded and type of ECG abnormality was described. An overall score of the euthanasia event was assigned using a numeric rating scale (NRS) after the animal was declared dead. The time to loss of corneal reflex was significantly longer in sheep given dexmedetomidine compared with those who received saline (P=0.03). Although vocalization was observed only in some animals premedicated with dexmedetomidine, no significance was found for this event and no other significant differences between groups were noted. Dexmedetomidine at 5μg/kg IV 5min prior to injection of pentobarbital/phenytoin for euthanasia did not substantially affect the progress of euthanasia. Dexmedetomidine may be given to sedate sheep prior to euthanasia without concern for it adversely affecting the progress of euthanasia, however vocalization may occur.