Neurological Care Research Articles

Left, Then Right ICA Dissection: A Case Report

ABSTRACT IntroductionWe present a unique case report of a patient who presented to the emergency departmentwith stroke-like symptoms found to have a spontaneous left sided internal carotid arterydissection. Case ReportThe patient was treated successfully with thrombectomy, and subsequently developedcontralateral symptoms caused by a right sided internal carotid artery dissection. This wasmanaged with a second contralateral thrombectomy. The patient’s course was complicated bypersistent and mild hypotension, postulated to be secondary to bilateral carotid baroreceptortrauma from the dissections. ConclusionThis case highlights the importance of close neurological monitoring for patients,preferably in a neurologic critical care setting, during and after invasive treatments such assystemic thrombolytic administration or mechanical thrombectomy, as identifying the patient’ssubsequent development of contralateral symptoms in a timely fashion was key to his positive outcome. An additional factor which had a positive impact on this outcome was the use of the RAPID Artificial Intelligence software which assists in determining whether thrombectomy maybe indicated prior to receiving a formal radiologist read on CT angiography/perfusion studies. AI technologies such as this have a great potential to augment and expedite patient care.

Brain Health Outcomes in Sexual and Gender Minority Groups: Results From the All of Us Research Program.

Sexual and gender minority (SGM) groups have been historically underrepresented in neurologic research, and their brain health disparities are unknown. We aim to evaluate whether SGM persons are at higher risk of adverse brain health outcomes compared with cisgender straight (non-SGM) individuals. We conducted a cross-sectional study in the All of Us Research Program, a US population-based study, including all participants with information on gender identity and sexual orientation. We used baseline questionnaires to identify sexual minority (lesbian, gay, bisexual, diverse sexual orientation; nonstraight sexual orientation) and gender minority (gender diverse and transgender; gender identity different from sex assigned at birth) participants. The primary outcome was a composite of stroke, dementia, and late-life depression, assessed using electronic health record data and self-report. Secondarily, we evaluated each disease separately. Furthermore, we evaluated all subgroups of gender and sexual minorities stratified by sex assigned at birth. We used multivariable logistic regression (adjusted for age, sex assigned at birth, race/ethnicity, cardiovascular risk factors, other relevant comorbidities, and neighborhood deprivation index) to assess the relationship between SGM groups and the outcomes. Of 413,457 US adults enrolled between May 31, 2017, and June 30, 2022, we included 393,041 participants with available information on sexual orientation and gender identity (mean age 51 [SD 17] years), of whom 39,632 (10%) belonged to SGM groups. Of them, 38,528 (97%) belonged to a sexual minority and 4,431 (11%) to a gender minority. Compared with non-SGM, SGM persons had 15% higher odds of the brain health composite outcome (odds ratio [OR] 1.15, 95% CI 1.08-1.22). In secondary analyses, these results persisted across sexual and gender minorities separately (all 95% CIs > 1). Assessing individual diseases, all SGM groups had higher odds of dementia (SGM vs non-SGM: OR 1.14, 95% CI 1.00-1.29) and late-life depression (SGM vs non-SGM: OR 1.27, 95% CI 1.17-1.38) and transgender women had higher odds of stroke (OR 1.68, 95% CI 1.04-2.70). In a large US population study, SGM persons had higher odds of adverse brain health outcomes. Further research should explore structural causes of inequity to advance inclusive and diverse neurologic care.

Brain health and national neurological societies: Results of the European Academy of Neurology survey on brain health awareness and areas of implementation for European countries.

The European Academy of Neurology (EAN) has adhered to the global plan for reducing the burden of neurological disorders and promoting brain health launched by the World Health Organisation (WHO), the WHO Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders. This study reports the results of an EAN survey among national neurological societies (NNSs) on their awareness of brain health policies. The EAN survey on the current state of national brain health policies was conducted among the 47 presidents of the NNSs affiliated with the EAN, with the aim of developing the best strategy for close collaboration among stakeholders. From June 2023 to February 2024, 36/47 responses (77%) were collected. Among respondents, 67% were in contact with their Ministry of Health and 78% were aware of and in contact with one or more national neurological patient organisation, while 17% had no contacts with any association. Ninety-two percent declared a high to medium degree of awareness of the need to support brain health and of brain health plans and strategies in their country. Our findings suggest good awareness of the importance of brain health and of the strategies implemented at the national level among the EAN-affiliated NNSs and representatives. Efforts towards improvement may be directed towards cooperation between NNSs and political institutions, as well as patient organisations, to optimise brain and global public health and neurological care in each country.

The Nursing Lens Contribution to Neurology, Neurosurgery, and Neurocritical Care.

The Nursing Lens Contribution to Neurology, Neurosurgery, and Neurocritical Care.

Less Common Mononeuropathies.

Uncommon mononeuropathies are challenging to diagnose as they can mimic joint pathology, radiculopathies, or plexopathies. They are less easily diagnosed due to unfamiliarity with their clinical presentation, knowledge of anatomy, and less commonly used diagnostic studies. A careful history, physical examination, and electrodiagnostic evaluation can help identify these neuropathies in a timely manner to administer the best treatment for resolution of symptoms. Recent advances in ultrasound and magnetic resonance techniques are used to confirm clinical suspicion of peripheral neuropathy by clearly depicting the anatomy and pathology as well as describing findings that mimic mononeuropathy. It is important for neurology, orthopedic, rheumatology, emergency, and primary care physicians to be familiar with less common mononeuropathies.

Feasibility Assessment of Rapid Response EEG in the Identification of Nonconvulsive Seizures During Military Medical Air Transport.

Traumatic brain injury often requires neurologic care and specialized equipment, not often found downrange. Nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE) occur in up to 30% of patients with moderate or severe traumatic brain injury and is associated with a 39% morbidity and an 18% mortality. It remains difficult to identify at bedside because of the heterogeneous clinical manifestations. The primary diagnostic tool is an electroencephalogram (EEG) which is large, requires an external power source, and requires a specialized technician and neurologist to collect and interpret the data. Rapid response EEG (rr-EEG) is an FDA-approved device that is pocket sized and battery powered and uses a disposable 10-electrode headset. Prior studies have demonstrated the noninferiority of rr-EEG in the identification of NCSE and NCS as compared to conventional EEG in hospitals. An unanswered question is whether rr-EEG could be used in the identification of NCSE and NCS by medics. In conjunction with the Critical Care Air Transport (CCAT) team, a simulation was created and implemented on a CCAT training mission. The simulation team included a neurology resident, who oversaw the simulation, a pulmonary critical care fellow, an intensive care unit nurse, and a respiratory therapy. A survey was provided before and after the simulation. The team was expected to review the rr-EEG to make clinical decisions during ground transport, takeoff, and landing. The neurology resident monitored and recorded the team's ability to distinguish between NCS and a normal EEG. In between, the neurology resident monitored the quality of the EEG for potential interference and loss of quality. The CCAT team was able to efficiently set up the rr-EEG on a patient manikin, correctly identify visual EEG wave forms of a patient in NCS, and utilize the proprietary audio program of a simulated patient in NCS. The team reported that the device was easily set up in the environment, and the data were interpretable despite vibration, aircraft auditory and electrical noise, and the ergonomics of the aircraft medical section. This pilot study has validated a potentially revolutionary technology in medical transport. The rr-EEG technology is measurably user-friendly and will improve patient outcomes. This device and simulation can reduce time to an EEG by hours to days allowing for immediate treatment and intervention, which can significantly reduce morbidity and mortality.

Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines

Background Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support. Methods These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels. Results We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts. Conclusions The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.

Championing nurse education in neurological care

Championing nurse education in neurological care

Exploring the relationship between neurologists and older persons with multiple sclerosis through the lens of social support theory.

Although healthcare practitioners (HCPs) are a valuable source of social support, research on support provided by neurologists to older persons with multiple sclerosis (pwMS) remains limited. To explore expectations of pwMS aged 55 years or older regarding MS care and to identify support types, met and unmet needs within their relationship with neurologists. Utilizing a mixed-methods approach, we analyzed survey data from Swiss Multiple Sclerosis Registry participants. Quantitative data included Likert scales gauging the importance of various aspects of MS care for pwMS both in and out of neurological care. Qualitative data were derived from three open-ended questions, focusing on neurologist-provided support for pwMS in neurological care. Data underwent descriptive and deductive thematic analysis, using Cutrona and Suhr framework for coding social support. Among the 286 participants (median age 61.0 years, interquartile range (IQR) 57.0-66.0; median disease duration 23.5 years, IQR 15.0-31.0), 84.6% (N = 244) were under neurological care. Quantitative findings highlighted the significance of HCP expertise and consultation time. Qualitative analysis identified all social support domains in the neurologist-pwMS relationship, with informational support being most prevalent, followed by emotional support. Neurologists' expertise, availability, comprehensive advising, listening, and validation emerged as key themes. Unmet needs were relatively infrequent and concerned insufficient information on complementary medicine, empathy, and understanding of symptoms like fatigue. Older pwMS see neurologists as adequate providers of comprehensive support and particularly value neurologists' sufficient availability, informational and emotional support. Areas for improvement include attention to complementary medicine and empathy.

Neurological care and outcomes in a cohort of Canadian pregnant patients with epilepsy

PurposeTo characterize anti-seizure medication (ASM) use over time, therapeutic drug monitoring, ASM dose adjustments and gestational seizure frequency among Canadian people with epilepsy of childbearing potential seen in an urban tertiary care center. MethodsParticipants were retrospectively identified from the medical records of pregnant patients with epilepsy seen at the University Health Network Epilepsy Clinic between 2014-2020. A descriptive analysis of outcomes, a logistic regression analysis of the odds of patients being on three ASMs associated with higher rates of teratogenicity (i.e., valproate, carbamazepine, and topiramate) over time, and a second logistic regression for predictors of seizure freedom during pregnancy were performed. Results195 pregnancies were included: 52% had a maternal diagnosis of generalized epilepsy and 92% were prescribed at least one ASM, with 75% on monotherapy. The majority underwent therapeutic drug monitoring (77%) with approximately two thirds requiring dose adjustments (69%), typically dosage increases (82%). The proportion of patients on either valproate, topiramate, or carbamazepine decreased over time (OR=0.80; p<0.01). Fifty-seven percent of pregnancies maintained seizure freedom, with seizure-freedom for ≥1 year prior to conception being the strongest predictor of this outcome (OR of gestational seizure recurrence=0.04; p<0.01). ConclusionThe proportion of patients on three ASMs associated with higher rates of teratogenicity has decreased over the duration of this study. Seizure-freedom prior to conception was associated with a decreased risk of gestational seizure recurrence.

Differences in Interfacility Transfer from Emergency Department and Inpatient Services for Inpatient Neurologic Care.

Interhospital transfer is an important mechanism for improving access to specialized neurologic care but there are large gaps in our understanding of interhospital transfer for the management of non-stroke-related neurologic disease. This observational study included consecutive patients admitted to an adult academic general neurology service via interhospital transfer from July 1, 2015 to July 1, 2017. Characteristics of the referring hospital and transferred patients were obtained through the American Hospital Association Directory, a hospital transfer database maintained by the accepting hospital, and the electronic medical record. The analyses used descriptive statistics to examine the cohort overall and compare characteristics of patients transferred from an emergency department and inpatient service. 504 patients were admitted via interhospital transfer during the study period. Of these, 395 patients (78.4%) were transferred because the referring hospital lacked capability, and 139 patients (27.6%) were transferred from an emergency department as opposed to inpatient service. Seizures was the most common diagnosis (23.8%). Patients who were transferred from an emergency department had a higher proportion covered by Medicaid (44.6%) than those transferred from an inpatient service (28.8%) and had a shorter median length of stay (3days; IQR 2-7 vs 7days; IQR 4-12). The majority of observed interhospital non-stroke neurologic transfers occurred to improve access to specialized neurological care for patients, though patients transferred from the ED, as opposed to an inpatient service, had lower health care utilization, and this will be important to consider when developing systems of care and in future research.

Navigating Neurologic Illness: Skills in Neuropalliative Care for Persons Hospitalized with Neurologic Disease.

Persons hospitalized for neurologic illness face multidimensional care needs. They can benefit from a palliative care approach that focuses on quality of life for persons with serious illness. We describe neurology provider "skills" to help meet these palliative needs: assessing the patient as a whole; facilitating conversations with patients to connect prognosis to care preferences; navigating neurologic illness to prepare patients and care partners for the future; providing high-quality end-of-life care to promote peace in death; and addressing disparities in care delivery.

Transition from paediatric to adult neurological care: What do we know?

IntroductionHealthcare advances have allowed an increase in the survival of paediatric patients with neurological diseases. As a result, it is increasingly common to find these patients in adult neurology consultations. The aim of this study is to evaluate the current level of consensus on the transition of neuropaediatric patients among neurology and paediatric professionals in the Balearic Islands. Material and methodsWe conducted an observational, analytical, cross-sectional study through an anonymous questionnaire consisting of 27 questions, which was distributed to neurologists, paediatric neurologists, hospital paediatricians, and primary care paediatricians in the healthcare network of the Balearic Islands. It was developed using Google Forms and distributed by the competent professional societies. Consensus was considered to exist for answers with 70% or more agreement. ResultsResponses were received from 58 professionals; 46.6% were hospital paediatricians, 29.9% were neurologists, 13.8% were paediatric neurologists, and 13.8% were primary care paediatricians. Among other issues, consensus was observed on the need for a transition programme for patients with neurological diseases. No consensus was observed regarding the duration of the transition (P=.029) and how long simultaneous follow-up must last after the transfer (P=.09). ConclusionsDue to increased survival rates, there is a need to create transition programmes for paediatric patients with neurological diseases. In our study, more than 70% of professionals believed that it would be beneficial to create such programmes.

Practical Approach to Longitudinal Neurologic Care of Adults With X-Linked Adrenoleukodystrophy and Adrenomyeloneuropathy.

Although X-linked adrenoleukodystrophy (ALD) has historically been considered a childhood disease managed by pediatric neurologists, it is one of the most common leukodystrophies diagnosed in adulthood. An increase in both male and female adults reaching diagnosis due to familial cases identified by state newborn screening panels and more widespread use of genetic testing results in a large cohort of presymptomatic or early symptomatic adults. This population is in urgent need of standardized assessments and follow-up care. Adults with ALD/adrenomyeloneuropathy (AMN) may be diagnosed in a variety of ways, including after another family member is identified via genetic testing or newborn screening, presenting for symptomatic evaluation, or following diagnosis with primary adrenal insufficiency. Significant provider, patient, and systems-based barriers prevent adult patients with ALD/AMN from receiving appropriate care, including lack of awareness of the importance of longitudinal neurologic management. Confirmation of and education about the diagnosis should be coordinated in conjunction with a genetic counselor. Routine surveillance for adrenal insufficiency and onset of cerebral ALD (CALD) in men should be performed systematically to avoid preventable morbidity and mortality. While women with ALD do not usually develop cerebral demyelination or adrenal insufficiency, they remain at risk for myeloneuropathy and are no longer considered "carriers." After diagnosis, patients should be connected to the robust support networks, foundations, and research organizations available for ALD/AMN. Core principles of neurologic symptom management parallel those for patients with other etiologies of progressive spastic paraplegia. Appropriate patient candidates for hematopoietic stem cell transplant (HSCT) and other investigational disease-modifying strategies require early identification to achieve optimal outcomes. All patients with ALD/AMN, regardless of sex, age, or symptom severity, benefit from a multidisciplinary approach to longitudinal care spearheaded by the neurologist. This review proposes key strategies for diagnostic confirmation, laboratory and imaging surveillance, approach to symptom management, and guidance for identification of appropriate candidates for HSCT and investigational treatments.

Neurologic Care for Transgender and Gender-Diverse People: A Review of Current Evidence and Clinical Implications.

To summarize the literature on neurologic care for transgender and gender-diverse (TGD) people and provide implications for clinical practice. There are limited data on the frequency and management of neurologic conditions among TGD people. TGD people have a higher prevalence of various neurologic conditions compared with cisgender or general population cohorts, including migraine, subjective cognitive decline, sleep disturbances, functional disorders, and cerebrovascular disease. Gender-affirming hormone therapy interacts with commonly prescribed neurologic medications and increases stroke risk among transfeminine people. Sex hormones and sex chromosomes may play a role in neurodegeneration and disability progression in neuroimmunologic diseases. Clitoral reduction surgeries on intersex children can cause neurologic disability and sexual dysfunction in adulthood. Socioeconomic disparities among TGD people contribute to health care barriers. Neurologists should consider the unique experiences and health care needs of TGD people in their clinical practice and research protocols.

Validation of optimised intracranial spectroscopic probe for instantaneous in-situ monitoring and classification of traumatic brain injury

The development of an optical interface to directly distinguish the brain tissue's biochemistry is the next step in understanding traumatic brain injury (TBI) pathophysiology and the best and most appropriate treatment in cases where in-hospital intracranial access is required. Despite TBI being a globally leading cause of morbidity and mortality in patients under 40, there is still a lack of objective diagnostical tools. Further, given its pathophysiological complexity the majority of treatments provided are purely symptomatic without standardized therapeutic targets. Our tailor-engineered prototype of the intracranial Raman spectroscopy probe (Intra-RSP) is designed to bridge the gap and provide real-time spectroscopic insights to monitor TBI and its evolution as well as identify patient-specific molecular targets for timely intervention. Raman spectroscopy being rapid, label-free and non-destructive, renders it an ideal portable diagnostics tool. In combination with our in-house developed software, using machine learning algorithms for multivariate analysis, the Intra-RSP is shown to accurately differentiate simulated TBI conditions in rat brains from the healthy controls, directly from the brain surface as well as through the rat's skull. Using clinically pre-established methods of cranial entry, the Intra-RSP can be inserted into a 2-piece optimised cranial bolt with integrated focussing and correctly identify a sample in real-life conditions with an accuracy >80 %. To further validate the Intra-RSP's efficiency as a TBI monitoring device, rat brains mildly damaged from inflicted spinal cord injury were found to be correctly classified with 94.5 % accuracy. Through optimization and rigorous in-vivo validation, the Intra-RSP prototype is envisioned to seamlessly integrate into existing standards of neurological care, serving as a minimally invasive, in-situ neuromonitoring tool. This transformative approach has the potential to revolutionize the landscape of neurological care by providing clinicians with unprecedented insights into the nature of brain injuries and fostering targeted, timely and effective therapeutic interventions.

Neuromonitoring in the ICU: noninvasive and invasive modalities for critically ill children and neonates

Purpose of review Critically ill children are at risk of neurologic dysfunction and acquiring primary and secondary brain injury. Close monitoring of cerebral function is crucial to prevent, detect, and treat these complications. Recent findings A variety of neuromonitoring modalities are currently used in pediatric and neonatal ICUs. These include noninvasive modalities, such as electroencephalography, transcranial Doppler, and near-infrared spectroscopy, as well as invasive methods including intracranial pressure monitoring, brain tissue oxygen measurement, and cerebral microdialysis. Each modality offers unique insights into neurologic function, cerebral circulation, or metabolism to support individualized neurologic care based on a patient's own physiology. Utilization of these modalities in ICUs results in reduced neurologic injury and mortality and improved neurodevelopmental outcomes. Summary Monitoring of neurologic function can significantly improve care of critically ill children. Additional research is needed to establish normative values in pediatric patients and to standardize the use of these modalities.

Effect evaluation of outpatient long-term video EEGs for people with seizure disorders – study protocol of the ALVEEG project: a randomized controlled trial in Germany

BackgroundEpilepsy and other seizure disorders account for a high disease burden in Germany. As a timely diagnosis and accurate treatment are crucial, improving the management of these disorders is important. Outside of Germany, outpatient long-term video EEGs (ALVEEGs) have demonstrated the potential to support the diagnosis and management of epilepsy and other seizure disorders. This study aims to evaluate the implementation of ALVEEGs as a new diagnostic pathway in eastern parts of Germany to diagnose epilepsy and other seizure disorders and to assess if ALVEEGs are equally effective as the current inpatient-monitoring gold standard, which is currently only available at a limited number of specialized centers in Germany.MethodsALVEEG is a prospective, multicenter, randomized controlled equivalence trial, involving five epilepsy centers in the eastern states of Germany. Patients will be randomized into either intervention (IG) or control group (CG), using a permuted block randomization. The sample size targeted is 688 patients, continuously recruited over the trial. The IG will complete an ALVEEG in a home setting, including getting access to a smartphone app to document seizure activity. The CG will receive care as usual, i.e., inpatient long-term video-EEG monitoring. The primary outcome is the proportion of clinical questions being solved in the IG compared to the CG. Secondary outcomes include hospital stays, time until video EEG, time until diagnosis and result discussion, patients’ health status, quality of life and health competence, and number and form of epilepsy-related events and epileptiform activity. Alongside the trial, a process implementation and health economic evaluation will be conducted.DiscussionThe extensive evaluation of this study, including an implementation and health economic evaluation, will provide valuable information for health policy decision-makers to optimize future delivery of neurological care to patients affected by epilepsy and other seizure disorders and on the uptake of ALVEEG into standard care in Germany.Trial registrationGerman Clinical Trials Register (DRKS00032220), date registered: December 11, 2023.

Pediatric Neuropalliative Medicine.

Neurological disease in childhood has significant impacts on not only physical well-being, but also on the social, environmental, and emotional health of the child, their family, and the larger community. Pediatric neuropalliative medicine is a recently developed area of subspecialty practice that supports families affected by serious neurological illness in navigating uncertain illness trajectories, refractory symptoms, and the myriad medical decisions that arise over the life of the child. Despite their medical needs, children with neurological diseases live full, joyful, and connected lives with their families, many of whom also experience personal growth and find meaning in their caregiving. Patients and families under the care of neurologists also face many systemic and interpersonal biases, both within the health care system and in the community, and encounter frequent gaps in their home and community-based supports. This chapter summarizes what is known about pediatric neuropalliative medicine and highlights the future research, educational, and clinical innovations that are needed to build more comprehensive and well-prepared systems to address unmet needs. Particularly in the modern era of child neurology practice where disease-modifying treatments are becoming increasingly available, pediatric neuropalliative medicine is an essential area of subspecialty practice that helps to support the personhood and quality of life of the individuals affected by serious illness and their families. As medicine helps more and more children with neurological impairment survive, medical treatment must include not only treatment for the physical body, but also care and support for the complexity of human experience of living with serious illness.

Multidisciplinary approach to repair of intra-articular fractures of the distal radius in a complicated setting (prehabilitation)

Introduction Treatment of malunited periarticular fracture of the distal metaepiphysis of the radius in a complicated setting is challenging and involved orthopaedic care and related specialties of neurologists, neurosurgeons and rehabilitation specialists. New methods are offered for repair of the distal radius fractures but the results obtained to date cannot be considered satisfactory, since the treatment is aimed at the restoration of the anatomical relationships and the hand function.The objective was to demonstrate the role of prehabilitation preparing patients for elective reconstructive surgery, to present a multidisciplinary approach to the treatment of malunited radius fracture complicated by posttraumatic compression ischemic multineuropathy.Material and methods The medical history of a 56-year-old patient with distal radius malunion complicated by posttraumatic compression ischemic multineuropathy was reviewed. Outcome criteria included absence of complaints and restored function of the hand and the wrist.Results A positive functional outcome was recorded after prehabilitation and surgery. Early postop, the DASH scored 35, palmar flexion measured 64° with dorsiflexion of 61° and dynamometry of 30 kg seen with the left involved hand. A faster recovery of the hand function occurred due to regression of neurological disorders.Discussion Treatment of the distal radius malunion in a complicated setting suggests the involvement of related specialists including neurologists, neurosurgeons, professionals in functional and diagnostic radiology, rehabilitation specialists so that the approach must be multidisciplinary. A preoperative course of prehabilitation supervised by a neurologist and a rehabilitation specialist is essential for the patient to achieve a higher basic level of functionality. Surgical treatment must be a stage of multi-stage multidisciplinary treatment of distal radius malunion in a complicated setting.Conclusion The clinical case showed an effective multidisciplinary approach in the treatment of distal radius malunion in a complicated setting. Preoperative preparation (prehabilitation) had a positive effect on the postoperative recovery and functional results.