C2 Level Research Articles

Extreme Lateral Approach to the Craniocervical Junction, Operative Technique and Approach Essentials: 2-Dimensional Operative Video.

The extreme lateral approach is useful for both extradural and intradural anterior and anterolateral lesions at the lower clivus down to the level of C2. The patient is evaluated with MRI, computed tomography (CT), and an angiogram. Special attention is given to vascular (vertebral artery course, dominance, tumor feeders) and bony (occipital condyle, jugular tubercle, foramen magnum and extent of bony involvement) anatomy. The patient is positioned lateral with the head flexed and tilted down without axial rotation. A hockey-stick incision is performed, and the myocutaneous flap is raised. A retrocondylar craniectomy is performed. The extradural vertebral artery is exposed for proximal control. A C1 hemilaminectomy is performed. Cephalad/caudal exposure and drilling of the occipital condyle are determined per case. The dura is opened, and the vertebral artery is released at the dural entry point to facilitate the tumor removal. The tumor is debulked and delivered inferoventrally away from the neuroaxis and cranial nerves. After removing the tumor, the dura is closed using an allograft.The patients consented to the procedure and to the publication of their images. • Cranial nerve deficits• Craniocervical instability• Postoperative hydrocephalus• Postoperative pseudomeningocele. A transmastoid extension of the craniectomy allows access further rostrally in the clivus. For C1-2 chordomas, the approach is extended inferiorly, and the vertebral artery is mobilized out of the C1-2 transverse foramina. For tumors involving the joints, an occipitocervical stabilization is required.Images in video reused with permission as follows: image at 00:16 from Revuelta Barbero et al, Endoscopic endonasal transclival-medial condylectomy approach for resection of a foramen magnum meningioma: 2-dimensional operative video, Oper Neurosurg, 16(2), 2018, by permission from the Congress of Neurological Surgery; images at 00:30, and top image at 00:52 reused from Wen et al, Microsurgical anatomy of the transcondylar, supracondylar, and paracondylar extensions of the far-lateral approach, J Neurosurg, 87(4), 1997, with permission from JNSPG; bottom images at 00:52 from Muthukumar et al, A morphometric analysis of the foramen magnum region as it relates to the transcondylar approach, Acta Neurochir, 147(8), 2005, by permission from Springer Nature.

Outpatient minimally invasive spine surgeries during the COVID-19 pandemic – A retrospective analysis of 164 consecutive cases

ObjectiveTo share our surgical experiences of minimally invasive cervical and lumbar procedures for patients who suffered from non-fatal motor vehicle accidents (MVAs) in the ambulatory surgery centers (ASCs) during the coronavirus disease 2019 (COVID-19) pandemic. MethodsAnterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), minimally invasive laminotomy and discectomy (MILD), percutaneous endoscopic laser-assisted discectomy (PELD) and percutaneous kyphoplasty (PK) were performed on carefully selected patients. ResultsFrom January 2020 to December 2021, our group performed 164 cases on 153 patients involving 249 intervertebral disc (IVD) levels. Of these, 116 cases (70.73%) on 114 patients (74.51%) were cervical, 48 cases (29.27%) were lumbar (including 8 PK cases). Eight patients had both cervical and lumbar procedures in a single anesthetic session (SAS) and were discharged on the same day. One hundred and six ACDF cases (92.17%) were at the C4–C5 and C5–C6 levels, which comprised of 146 (76.04%) IVDs. Of the 40 non-PK lumbar cases, 38 (95.0%) were at L4 to S1 lumbar levels. Six of these cases (15.0%) involved 2 lumbar levels. In contrast, 6 out of 8 kyphoplasties (75.0%) involved lower thoracic/higher lumbar vertebral columns (T11 to L2) and 2 were at the lower lumbar L4 level. ConclusionsWe successfully and safely performed various cervical and lumbar spine surgeries in the ASCs amid COVID-19 pandemic and all patients achieved the same-day discharge (SDD). In the non-fatal MVAs, mid-lower cervical (C4 to C6) and lower lumbar (L4 to S1) IVDs were the most affected levels.

Glomus tumor mimicking as cervical radiculopathy

Glomus tumors are rare, painful, and usually benign neoplasms typically occurring at the subungual aspect of digits. Patients usually complain of extremely painful episodes. Symptoms occur spontaneously or elicited by local compression and cold environment, in special if the tumor has an acral location. We describe a case of cervical radiculopathy caused by glomus tumor which developed spontaneously causing pain at the right index finger. Pain was excruciating, which increased on touching and sudden striking on objects. There was no neck pain, no sensory loss, and no weakness. Pain radiates to the elbow and sometimes shoulders. The patient was given trial of neuropathic medications without much relief. Nerve conduction studies were normal. Magnetic resonance imaging spine minimal disk bulge at C5–C6 level with no neural compression. On examination, the neck movements were normal and power, tone, and reflexes were normal. Neurological examination was normal. Severe tenderness on palpating the right index finger nail. MRI of the right index finger revealed a glomus tumour. Glomus tumor was diagnosed and the patient underwent surgical excision. There can be a delay in diagnosis in glomus tumours.Cervical radiculopathy may be diagnosed erroneously in patients if careful physical examination and investigations are not done.

ANALISIS KEMAMPUAN PEMECAHAN MASALAH SISWA DALAM MENYELESAIKAN SOAL MATEMATIKA TIPE HOTS PADA MATERI POKOK PERBANDINGAN

This study aims to find out the description of the ability of students in solving mathematical questions type Higher Order Thinking Skill (HOTS) comparative material in class VII. This research uses descriptive research using a qualitative approach. The subjects selected in this study were 3 students, the selection technique is based on each 1 student from a high-capability student group, 1 students from a medium-capable group and 1 student of a low-capacity group. Students with high cognitive abilities at C4 (analysing), C5 (evaluating), and C6 (creating) level are able to solve HOTS issues, as well as meet all phases of problem solving. But at the cognitive level C5 (evaluating) is not able to complete the entire phase of problem solving (3) Students with low cognitiveness at the level C4 (analysing), C 5 (assessing), and C 6 (creating) are unable to solve the HOTS issue and are only able to meet the stage of solving the problem of information compilation alone.

Investigating HOTS on Reading Questions from Fiction Text of the English Textbook Used by Vocational High Schools in Indonesia

Higher-order thinking skills become the target for learning outcomes in the current curriculum. The integration of those thinking levels must be included in the textbook. The English textbook is a kind of media for the students and teachers doing the learning process. A qualified book should provide HOTS instructions to achieve the current curriculum’s goal. This study aims to analyze the use of HOTS in reading questions in fiction texts and find the most dominant thinking skills used. This study was descriptive qualitative research. The data was the reading questions on fiction texts, and the data source is an English textbook titled “English In Mind” a second edition published by the Ministry of Research, Technology and Higher Education Indonesia for grade X used by Vocational High Schools. The researcher used documentation as the collecting data technique, and the technique of analyzing data used was from Miles and Huberman. They are data collection, reduction, and display; the last is the conclusion or verification. The finding of this study is this book has developed HOTS. 53,33% belong to C4, and 46,66% belong to C5 level and the most dominant thinking skillare at C4 or analysis level. The conclusion is that eight fiction texts contain fifteen reading questions integrating HOTS.

Identifying Intraoperative Spinal Cord Injury Location from Somatosensory Evoked Potentials' Time-Frequency Components.

Excessive distraction in corrective spine surgery can lead to iatrogenic distraction spinal cord injury. Diagnosis of the location of the spinal cord injury helps in early removal of the injury source. The time-frequency components of the somatosensory evoked potential have been reported to provide information on the location of spinal cord injury, but most studies have focused on contusion injuries of the cervical spine. In this study, we established 19 rat models of distraction spinal cord injury at different levels and collected the somatosensory evoked potentials of the hindlimb and extracted their time-frequency components. Subsequently, we used k-medoid clustering and naive Bayes to classify spinal cord injury at the C5 and C6 level, as well as spinal cord injury at the cervical, thoracic, and lumbar spine, respectively. The results showed that there was a significant delay in the latency of the time-frequency components distributed between 15 and 30 ms and 50 and 150 Hz in all spinal cord injury groups. The overall classification accuracy was 88.28% and 84.87%. The results demonstrate that the k-medoid clustering and naive Bayes methods are capable of extracting the time-frequency component information depending on the spinal cord injury location and suggest that the somatosensory evoked potential has the potential to diagnose the location of a spinal cord injury.

The acute effects of motor imagery and cervical transcutaneous electrical stimulation on manual dexterity and neural excitability

Transcutaneous electrical stimulation (TCES) of the spinal cord induces changes in spinal excitability. Motor imagery (MI) elicits plasticity in the motor cortex. It has been suggested that plasticity occurring in both cortical and spinal circuits might underlie the improvements in performance observed when training is combined with stimulation. We investigated the acute effects of cervical TCES and MI delivered in isolation or combined on corticospinal excitability, spinal excitability and manual performance. Participants (N = 17) completed three sessions during which they engaged in 20 min of: 1) MI, listening to an audio recording instructing to complete the purdue pegboard test (PPT) of manual performance; 2) TCES at the spinal level of C5–C6; 3) MI + TCES, listening to the MI script while receiving TCES. Before and after each condition, we measured corticospinal excitability via transcranial magnetic stimulation (TMS) at 100% and 120% motor threshold (MT), spinal excitability via single-pulse TCES and manual performance with the PPT. Manual performance was not improved by MI, TCES or MI + TCES. Corticospinal excitability assessed at 100% MT intensity increased in hand and forearm muscles after MI and MI + TCES, but not after just TCES. Conversely, corticospinal excitability assessed at 120% MT intensity was not affected by any of the conditions. The effects on spinal excitability depended on the recorded muscle: it increased after all conditions in biceps brachii (BB) and flexor carpi radialis (FCR); did not change after any conditions in the abductor pollicis brevis (APB); increased after TCES and MI + TCES, but not after just MI in the extensor carpi radialis (ECR). These findings suggest that MI and TCES increase the excitability of the central nervous system through different but complementary mechanisms, inducing changes in the excitability of spinal and cortical circuits. MI and TCES can be used in combination to modulate spinal/cortical excitability, an approach particularly relevant for people with limited residual dexterity who cannot engage in motor practice.

Clinical Outcomes of Open-Door Laminoplasty Combined with Bilateral Lateral Mass Screw Fixation for Multi-Level Cervical Spinal Stenosis with Traumatic Cervical Instability and Spinal Cord Injury: A Retrospective Study.

The prevalence of multi-level cervical spinal stenosis complicated with traumatic cervical instability and spinal cord injury (MCSS-TCISCI) is low, and the optimal surgical approach remains unclear. Open-door laminoplasty combined with bilateral lateral mass screw fixation (ODL-BLMSF) is a relatively new surgical technique; however, its clinical effectiveness in managing MCSS-TCISCI has not been well-established. This study aims to assess the clinical value of ODL-BLMSF against MCSS-TCISCI. We retrospectively analyzed 20 cases of MCSS-TCISCI treated with ODL-BLMSF from July 2016 to June 2020. Radiographic alterations of all included patients were measured using plain radiographs, CT scans, and MRI scans. Cervical lordosis was evaluated using C2-C7 Cobb angle and cervical curvature index (CCI) on lateral radiographs, and Pavlov ratio at the C5 level. Neurological functional recovery was assessed using Japanese Orthopaedic Association (JOA) scores and Nurick grade, while neck and axial symptoms were assessed using the neck disability index (NDI) and the visual analog scale (VAS). The paired t-test was utilized for statistical analysis. All included patients were followed up for an average period of 26.5 months (range: 24-30 months) after ODL-BLMSF. The average Pavlov ratio at the C5 level significantly improved from 0.57 ± 0.1 preoperatively to 1.13 ± 0.1 and 1.12 ± 0.04 at 6 months postoperatively and at the last follow-up (t = 16.347, 16.536, p < 0.001). Importantly, this approach significantly increased the JOA score from 5.0 ± 2.6 before surgery to 11.65 ± 4.3 and 12.1 ± 4.3 at 6 months postoperatively and at the last follow-up (t = 9.6, -9.600, p < 0.001), with an average JOA recovery rate of 59.1%; and the average Nurick disability score decreased from 3.0 ± 1.3 (preoperative) to 1.65 ± 1.22 and 1.5 ± 1.2 (6 months postoperatively and at last follow-up) (t = 5.111, 1.831, p < 0.001). Meanwhile, the NDI score decreased from 30.3 ± 4.3 preoperatively to 13.2 ± 9.2 at 6 months (t = 12.305, p < 0.001), and to 12.45 ± 8.6 at the final follow-up (t = 13.968, p < 0.001), while the VAS score decreased from 4.0 ± 1.5 preoperatively to 1.5 ± 0.7 at 6 months (t = 9.575, p < 0.001), and to 1.15 ± 0.7 at the final follow-up (t = 10.356, p < 0.001). ODL-BLMSF can effectively dilate the stenotic spinal canal to decompress the spinal cord, maintain good cervical alignment and stability, and improve the recovery of neurological function and neck function. This technique is suitable for treating selected cases of MCSS-TCISCI.

Biomechanical analysis of a single-level customized cage screw fixation for anterior cervical discectomy and fusion in the cervical spine: an in-silico study

The usual surgical choice of customized cage fixation is anterior cervical discectomy and fusion (ACDF) for cervical spondylosis with disc herniation. The safe and successful cage fixation for ACDF surgery benefits patients with cervical disc degenerative disease by easing their discomfort and regaining function. The cage prevents mobility between the vertebrae by using cage fixation to anchor the neighbouring vertebrae. The goal of the current study is to develop a customized cage-screw implant for single-level cage fixation at C4–C5 level of the cervical spine (C2–C7). The Finite Element Analysis (FEA) is performed for the intact and implanted cervical spine and analysed the flexibility, stress of the implant and implant adjacent bone during three physiological loading conditions being analysed. Lower surface of the C7 vertebrae is fixed and 50 N compressive force with 1 Nm moment are applied on the C2 vertebrae for simulated lateral bending, axial rotation and flexion-extension. The flexibility is decreased at single level of fixation (C4–C5 level) by 64% to 86%, as compared to natural cervical spine. The flexibility is increased 3% to 17% at the nearest levels of fixation. The maximum Von Mises stress in PEEK cage varies from 24 to 59 MPa and for Ti-6Al-4V screw the stress varies from 84 MPa to 121 MPa which are far below the yield stress of PEEK (95 MPa) and Ti-6Al-4V (750 MPa).

SCALING OLYMPUS: EXPLORING OFFICIAL LANGUAGE CERTIFICATIONS AT THE CEFR C2 LEVEL

For many foreign language learners, passing an examination at the C2 level – the sixth and highest level of the Council of Europe’s Common European Framework of Reference for Languages (CEFR) – can seem like a lofty goal. For educators, preparation requirements at this level can also be challenging, especially given common misconceptions about the degree of linguistic skill and knowledge required for candidates to complete the relevant qualification successfully. Accordingly, in first outlining the rationale and requirements for the CEFR C2 level according to the Council of Europe’s guidelines, this contribution aims to explore the official language qualifications available at this level of proficiency. As such, the range of accredited C2-level language certifications offered by institutional full members of the Association of Language Testers in Europe (ALTE) will be investigated, primarily through analysis of the relevant websites for each individual C2 qualification. In comparing and contrasting these advanced-level examinations, which are offered across a range of European languages, it is intended to offer greater insights into the varying formats, structures, and requirements of official language certifications at the C2 level. Thus, it is intended to provide practical benefits not only for educators, but also for foreign language learners and examination candidates seeking to prepare for these qualifications.

Bihemispheric posterior inferior cerebellar artery in a cadaver with Chiari I malformation.

Typically, patients with Chiari I malformations (CM I) do not have other intracranial anatomical variations, especially vascular derailments. Here, we report the findings of a cadaveric specimen found to have CM I and cerebellar tonsils supplied by a single posterior inferior cerebellar artery (PICA) i.e., a bihemispheric PICA. An adult male cadaver was found to have CM I. It was also noted that the left PICA descended inferiorly to the level of C1 and that there was absence of the right PICA. The territory of the right PICA was supplied by the left PICA. The tonsillar component of the left PICA gave rise to a branch that crossed to the right inferior cerebellum and herniated cerebellar tonsil. A bihemispheric PICA is very rare. To our knowledge, this is the first report of this vascular variation in combination with CM I. Such a variation should be kept in mind, especially during posterior fossa decompression for symptomatic CM I as unilateral PICA injury could have catastrophic results.

Teaching english using mobile applications to improve academic performance and language proficiency of college students.

The purpose of the study is to determine the effectiveness of mobile applications in conjunction with the students' online collaboration in the educational environment of Chinese colleges (the context of learning English). The students were selected from all those who study English in their educational programs. At the first stage, they passed a test on the level of language knowledge and among 423 students 140 were selected who had a level of B2 and below. Then they were divided into control and experimental groups. Each had 70 people. The experimental group was trained using the following mobile applications: Busuu, Lingoda, LinguaLeo, BBC Learning English. The results showed that the participants in the experimental group scored higher on the final test (74.71) than the control group participants (65.9). It suggests that mobile learning technologies can improve student achievement. The preliminary test determined the level of knowledge of the experimental group students in this way: 85% of students know English at the B2 level, 14% - B1, and 1% - A2. These figures improved significantly in the second test: the number of students who reached the C2 level was 7%, C1-79%, and 14% of all students remained with the B2 level. For the control group students, these indicators remained unchanged. Most of the students found this format of education suitable and interesting for online collaboration. These results may be useful for teaching practice, because they provide evidence base with the experimental research for the introduction of mobile technologies in the modern educational process. It solves the problem of using the certain mobile applications (Busuu, Lingoda, LinguaLeo, BBC Learning English) that have not been explored before.

Effects of Stimulus Pattern on Inspiratory Muscle Activation during High Frequency Spinal Cord Stimulation in an Animal Model

Background: High Frequency Spinal Cord Stimulation (HF-SCS) is a unique method of inspiratory muscle activation and has the potential to restore breathing in ventilator dependent tetraplegic subjects. Objective: To evaluate the pattern of diaphragm (D), parasternal (PA) and external intercostal (EI) activation during rectangular vs ramp-shape HF-SCS, compared to spontaneous breathing. Methods: In 8 anesthetized dogs, a stimulating disc electrode was positioned on the ventral surface of the spinal cord at the T2 level. Stimulus train duration for ramp-shape and rectangular HF-SCS was set at 1.3s since this duration approximated that occurring during spontaneous breathing. Stimulus amplitude during HF-SCS was adjusted such that inspired volumes approximated that occurring during SB. The ramp-shape pattern of stimulation was linearly increased from zero to the desired stimulus amplitude. Single motor unit (SMU) EMG activity of the PA, EI and D muscles was assessed during SB and HF-SCS (following spinalization at the C2 level) with rectangular and ramp-shape stimulation patterns, in separate trials. Time of onset (To), b) time to peak discharge frequency (TTP) and c) peak firing frequency (PFF) were measured under each condition. To and TTP were determined relative to the onset of inspiratory flow and expressed as a percentage of inspiratory time (Ti). The patterns of the inspiratory muscle activation during HF-SCS were compared to that obtained during spontaneous breathing. Results: During SB, D was recruited first followed by PA and EI; mean ± SE To was 19.6±1.4, 32.1±2.4 and 40.4±2.3%Ti, respectively. During rectangular HF-SCS, To was 3.0±0.4, 5.8±1.2 and 4.3±0.9%Ti for D, PA and EI, respectively (p&lt;0.05 for each compared to SB). During ramp-shape HF-SCS, To was 23.1±3.7, 33.6±4.5 and 39.9±4.6%Ti for D, PA and EI respectively (NS for each compared to SB). During SB, TTP was 65.2±2.2, 71.0±2.0 and 74.0±2.0%Ti for D, PA and EI. During rectangular HF-SCS, TTP was 30.4±3.7, 25.4±3.3 and 35.2±2.8%Ti, for D, PA and EI (p&lt;0.05 for each compared to SB). During ramp-shape HF-SCS, TTP was 60.5±2.9, 58.2±2.7 and 62.6±6.0%Ti for Dia, PA and EI (p&lt;0.05 for PA and EI compared to SB). During SB, PFF of SMUs of the D, PA and EI were 10.3±0.5, 12.8±0.4 and 12.2±0.7Hz, respectively. However, during rectangular HF-SCS, PFF were 14.0±0.6, 14.7±0.7 and 14.5±0.5Hz for D, PA and EI, respectively (p&lt;0.05 for each compared to SB). During ramp-shape HF-SCS, PFF were 12.3±0.8, 13.8±0.9 and 12.6±1.2 for D, PA and EI, respectively (NS for each compared to SB). Conclusion: Activation of the inspiratory motoneuron pools via HF-SCS is receptive to different patterns of electrical stimulation.Ramp-shape HF-SCS compared to rectangular HF-SCS results in a more physiologic pattern of inspiratory muscle activation. National Institutes of Health grant no. R01 NS105785. Conflict of interest: Dr. A. DiMarco is a founder of and has a significant financial interest in Synapse BioMedical, a manufacturer of diaphragm pacing systems (nos. 5,678,535 and 5,911,218). Dr. A. DiMarco and Dr. K. Kowalski hold the U.S. patents for technology related to the content of this study, Respiratory Muscle Activation by Spinal Cord Stimulation (no. 8,352,036). This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Anatomical and epidemiological examination of the structure and localization of osteophytes of cervical vertebrae in geriatric patients by using computed tomography method

Background: To evaluate the osteophytes seen in the cervical vertebrae of geriatric individuals in various parameters. Materials and Methods: 764 (M: 413, F: 351) individuals who were admitted to the State Hospital Radiology Outpatient Clinic with various complaints between the years 2018 and 2023 and who met the criteria were examined in our study. A total of 1209 osteophytes were found in the individuals. The osteophytes were evaluated in terms of gender, age, grade, vertebral level, vertebral spacing, anatomical aspect, anatomical surface and length parameters. Results: Osteophyte formation increased with age in individuals (p&amp;lt;0.05). Osteophyte formation was observed more frequently in men when compared to women (p&amp;gt;0.05). Claw type osteophytes were observed commonly in all individuals (p&amp;lt;0.05). While fused type osteophytes were observed commonly in men, traction-type osteophytes were observed more frequently in women (p&amp;lt;0.05). Osteophyte formation of grade 2 severity was observed in all individuals (p&amp;gt;0.05). While fused osteophytes were commonly observed at grade 4 severity, claw and traction type osteophytes were observed at grade 2 severity (p&amp;lt;0.05). Osteophytes were commonly observed at the C5 vertebra level in all individuals (p&amp;gt;0.05). Fused and traction type osteophytes were commonly seen at the C6 level, while claw type osteophytes are commonly seen at the C5 level (p&amp;lt;0.05). In all individuals, osteophytes were most common in the C5-6 space, followed by the C4-5, C6-7 (p&amp;gt;0.05). Osteophytes were commonly seen anteriorly in both sexes and all osteophyte types (p&amp;lt;0.05). All osteophyte types were commonly observed in the inferior surface of the vertebra (p&amp;lt;0.05). Males had relatively longer osteophytes (mm) than females (p&amp;lt;0.05). Claw type osteophyte was observed in longer dimensions than traction type osteophyte (p&amp;lt;0.05) Conclusions: Osteophyte type and grade severity were found to vary between individuals. In the examinations, varying features were observed in the vertebral level, anatomical aspect, surface and length parameters of the osteophytes.

Migraine treatment with GON blockade at the level of C2: The tip of the iceberg and the submerged portion

Migraine treatment with GON blockade at the level of C2: The tip of the iceberg and the submerged portion

Neurosarcoidosis presenting as Brown-Sequard Syndrome: A Case Report (P9-5.010)

<h3>Objective:</h3> N/A <h3>Background:</h3> Sarcoidosis is an auto-inflammatory condition resulting in diffuse noncaseating granulomatous disease without a clear etiology. The chronic inflammatory state can lead to the involvement of the lungs, kidneys, skin, joint spaces, and more rarely, the nervous system. Neurosarcoidosis most often manifests as cranial mononeuropathies, most likely impacting cranial nerves VII and VIII. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> This case report discusses a 50-year-old male with a past medical history of HIV, presenting with right leg numbness, right chest paresthesia and left sided motor deficits involving both the upper and lower extremities – consistent with Brown-Sequard syndrome. Cervical spinal MRI was significant for a 7.8 × 7 mm nodular enhancing, intramedullary lesion at the level of C5–C6 with edema extending up to C2 and down to T1. The patient was referred to neurosurgery due to the suspicion of a cord compressing tumor such as an ependymoma or astrocytoma. Computed tomography scan of the abdomen and pelvis displayed mediastinal lymphadenopathy. A subsequent bronchoscopy demonstrated cobblestone studding consistent with sarcoidosis and endobronchial biopsy confirmed the presence of non-caseating granulomas. Cerebrospinal fluid analysis was negative for infection. The patient was diagnosed with neurosarcoidosis and treated with high dose steroids which resulted in significant improvement of symptoms. <h3>Conclusions:</h3> His diagnosis also explains his history of right sided Bell’s palsy in 2017. His active HIV infection allowed his sarcoidosis to remain asymptomatic due to a lack of antibody response and depleted levels of CD4. Once the patient began treatment and his CD4/CD8 count rose, his sarcoidosis became symptomatic leading to his current presentation. This is the only reported case of sarcoidosis presenting as a Brown-Sequard pattern of spinal cord involvement. The purpose of this case report is to contribute to our understanding of different possible presentations of neurosarcoidosis. <b>Disclosure:</b> Ms. Patel has nothing to disclose. Dr. Dunse has nothing to disclose. Dr. Husar has nothing to disclose.

An Atypical Manifestation of Lateral Medullary Syndrome (P12-5.011)

<h3>Objective:</h3> To describe a case of lateral medullary syndrome (LMS) presenting with ipsilateral hemiparesis and upper motor neuron (UMN)-type facial palsy. <h3>Background:</h3> LMS is a classical vascular syndrome involving the posterior inferior cerebellar artery, which presents typically with ipsilateral Horner syndrome, ipsilateral ataxia, and contralateral hemianesthesia. Motor weakness and facial palsy are not traditionally presented in LMS. <h3>Design/Methods:</h3> Case report. <h3>Results:</h3> A 62-year-old male with poorly controlled hypertension presented with sudden onset left hemiparesis. On presentation, initial blood pressure was 178/95 mmHg. The neurological exam showed dysarthria, left facial palsy sparing the forehead, left facial hypoesthesia, and left hemiparesis (NIHSS 8). Diffusion-weighted MR Brain showed acute infarct in the left lateral medulla. FLAIR sequence showed chronic infarct in the right thalamus. CT arteriogram revealed non-opacification of the left vertebral artery at the level of C2–C3 with opacification of the distal left V4 via retrograde flow, severe stenosis of the right M1 segment, and multifocal atherosclerosis of the bilateral internal carotid arteries. Initial labs showed elevated LDL (213 mg/dl) and normal hemoglobin A1c. Right hemianesthesia was reported during his hospitalization; dysphagia, frequent hiccups, and left dysmetria out of proportion to weakness were noted during the recovery. After acute interventions, he was started on dual antiplatelet treatments for 90 days and a single antiplatelet afterward given concerns of large vessel disease as stroke etiology. <h3>Conclusions:</h3> Atypical clinical presentation in this LMS case included the combination of ipsilateral hemiparesis and ipsilateral UMN-type facial palsy. LMS with ipsilateral hemiparesis is known as Opalski’s syndrome, which is explained by involving the post-decussating pyramidal tract at the lower medulla and upper cervical spine. The explanation of ipsilateral UMN-type facial palsy in our case remains unclear. One possible explanation is the aberrant caudal looping of facial corticobulbar fibers into medulla oblongata prior to synapsing with the pontine facial nucleus. <b>Disclosure:</b> Dr. Yu has nothing to disclose. Mr. Bluntson has nothing to disclose. Dr. Sharma has nothing to disclose.

Ultrasonography is an effective tool for the evaluation of traumatic vertebral artery injuries distal to fourth cervical vertebra in the emergency room

BackgroundThis study aimed to determine the feasibility of ultrasonography in the assessment of cervical vertebral artery (VA) injury as an alternative to computed tomography angiography (CTA) in the emergency room.MethodsWe analyzed 50 VAs from 25 consecutive patients with cervical spine injury that had been admitted to our emergency room. Ultrasonography and CTA were performed to assess the VA in patients with cervical spine injury. We examined the sensitivity and specificity of ultrasonography compared with CTA.ResultsAmong these VAs, six were occluded on CTA. The agreement between ultrasonography and CTA was 98% (49/50) with 0.92 Cohen's Kappa index. The sensitivity, specificity, and positive and negative predictive values of ultrasonography were 100%, 97.7%, 85.7%, and 100%, respectively. In one case with hypoplastic VA, the detection of flow in the VA by ultrasonography differed from detection by CTA. Meanwhile, there were two cases in which VAs entered at C5 transverse foramen rather than at C6 level. However, ultrasonography could detect the blood flow in these VAs.ConclusionsUltrasonography had a sensitivity of 100% compared with CTA in assessment of the VA. Ultrasonography can be used as an initial screening test for VA injury in the emergency room.

Neurophysiological Evaluation of Neural Transmission in Brachial Plexus Motor Fibers with the Use of Magnetic versus Electrical Stimuli.

The anatomical complexity of brachial plexus injury requires specialized in-depth diagnostics. The clinical examination should include clinical neurophysiology tests, especially with reference to the proximal part, with innovative devices used as sources of precise functional diagnostics. However, the principles and clinical usefulness of this technique are not fully described. The aim of this study was to reinvestigate the clinical usefulness of motor evoked potential (MEP) induced by a magnetic field applied over the vertebrae and at Erb's point to assess the neural transmission of brachial plexus motor fibers. Seventy-five volunteer subjects were randomly chosen to participate in the research. The clinical studies included an evaluation of the upper extremity sensory perception in dermatomes C5-C8 based on von Frey's tactile monofilament method, and proximal and distal muscle strength by Lovett's scale. Finally, 42 healthy people met the inclusion criteria. Magnetic and electrical stimuli were applied to assess the motor function of the peripheral nerves of the upper extremity and magnetic stimulus was applied to study the neural transmission from the C5-C8 spinal roots. The parameters of compound muscle action potential (CMAP) recorded during electroneurography and MEP induced by magnetic stimulation were analyzed. Because the conduction parameters for the groups of women and men were comparable, the final statistical analysis covered 84 tests. The parameters of the potentials generated by electrical stimulus were comparable to those of the potentials induced by magnetic impulse at Erb's point. The amplitude of the CMAP was significantly higher following electrical stimulation than that of the MEP following magnetic stimulation for all the examined nerves, in the range of 3-7%. The differences in the potential latency values evaluated in CMAP and MEP did not exceed 5%. The results show a significantly higher amplitude of potentials after stimulation of the cervical roots compared to potentials evoked at Erb's point (C5, C6 level). At the C8 level, the amplitude was lower than the potentials evoked at Erb's point, varying in the range of 9-16%. We conclude that magnetic field stimulation enables the recording of the supramaximal potential, similar to that evoked by an electric impulse, which is a novel result. Both types of excitation can be used interchangeably during an examination, which is essential for clinical application. Magnetic stimulation was painless in comparison with electrical stimulation according to the results of a pain visual analog scale (3 vs. 5.5 on average). MEP studies with advanced sensor technology allow evaluation of the proximal part of the peripheral motor pathway (between the cervical root level and Erb's point, and via trunks of the brachial plexus to the target muscles) following the application of stimulus over the vertebrae.

Childhood posterior circulation arterial ischemic stroke – An unusual case with a possible COVID-19-related arteriopathy

Viral infections are known to increase predilection to stroke and coronavirus disease 2019 (COVID-19) has proven these concerns true. We are presenting the case of a 6-year-old previously normal male child diagnosed with posterior circulation stroke who had all etiological workups negative except for the COVID antibody. Imaging showed thrombi over the V3 segment of the vertebral artery at C1–C2 level causing near complete occlusion, with embolic infarct in the bilateral posterior inferior cerebellar artery, bilateral posterior cerebral artery, bilateral anterior inferior cerebellar artery, and the left superior cerebellar artery. The child was managed with methylprednisolone, anticoagulation, and supportive care and was able to restore near-normal neurological status within months. This case is unique in terms of the involvement of posterior circulation which is rare in the pediatric population. A possibility of inflammation-related arteriopathy secondary to infection should be considered in the etiological workup of stroke. Anti-inflammatory measures to control cytokine storm along with supportive care will ensure a good outcome.