Cervical Cord Lesions Research Articles

Can compressive thoracic cord lesions cause a pure lower motor neurone syndrome?

Compressive lesions of the spinal cord usually cause a syndrome of upper motor neurone weakness, spasticity and sensory loss below the level of the lesion. It has long been recognised...

Restless Legs Syndrome/Willis-Ekbom Disease in Multiple Sclerosis Patients with Spinal Cord Lesions.

Spinal cord lesions in Multiple Sclerosis (MS) patients are associated with a higher risk of restless legs syndrome (RLS). In this study, we investigated the prevalence of RLS, sleep quality, presence and severity of depression, and the relationship of these parameters with cervical cord lesions in patients with RRMS. This study was conducted in the outpatient multiple sclerosis clinic of Marmara University Hospital between October 2013 - February 2014, including 93 patients with the diagnosis of MS. After signing informed consent, demographic data, comorbidities and actual medication of the patients were collected. All patients completed the surveys including Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS) and Beck Depression Inventory (BDI). Prevalence of HBS, sleep quality and depression severity were compared between those with and without cervical cord lesions. Furthermore, the relationship between RLS and sleep quality, depression and expanded disability status scale (EDSS) was assessed. From overall patients, 72% were women (n=67) and 28% (n=26) were men. From all subjects, 32% (n=30) fulfilled IRLSSG diagnostic criteria. Fifty-seven percent of the patients (n=53) had pathological spinal cord lesions. Patients with RLS had significantly higher prevalence of pathological spinal cord lesions compared to patients without RLS (p=0.04). Sleep quality was found to be poor in both patients with cervical cord lesions and patients with RLS and this was statistically significant (p=0.031, p=0.0001). In summary, the possibility of RLS development in RRMS patients increases with the presence of lesions in spinal cord. Sleep quality was found to be poor in both patients with cervical cord lesions and patients with RLS. As RLS is a potentially treatable condition, increased awareness of diagnosis of RLS in MS patients may be important for early treatment and improve the comfort of the patient.

Validation of mean upper cervical cord area (MUCCA) measurement techniques in multiple sclerosis (MS): High reproducibility and robustness to lesions, but large software and scanner effects

IntroductionAtrophy of the spinal cord is known to occur in multiple sclerosis (MS). The mean upper cervical cord area (MUCCA) can be used to measure this atrophy. Currently, several (semi-)automated methods for MUCCA measurement exist, but validation in clinical magnetic resonance (MR) images is lacking.MethodsFive methods to measure MUCCA (SCT-PropSeg, SCT-DeepSeg, NeuroQLab, Xinapse JIM and ITK-SNAP) were investigated in a predefined upper cervical cord region. First, within-scanner reproducibility and between-scanner robustness were assessed using intra-class correlation coefficient (ICC) and Dice's similarity index (SI) in scan-rescan 3DT1-weighted images (brain, including cervical spine using a head coil) performed on three 3 T MR machines (GE MR750, Philips Ingenuity, Toshiba Vantage Titan) in 21 subjects with MS and 6 healthy controls (dataset A). Second, sensitivity of MUCCA measurement to lesions in the upper cervical cord was assessed with cervical 3D T1-weighted images (3 T GE HDxT using a head-neck-spine coil) in 7 subjects with MS without and 14 subjects with MS with cervical lesions (dataset B), using ICC and SI with manual reference segmentations.ResultsIn dataset A, MUCCA differed between MR machines (p < 0.001) and methods (p < 0.001) used, but not between scan sessions. With respect to MUCCA values, Xinapse JIM showed the highest within-scanner reproducibility (ICC absolute agreement = 0.995) while Xinapse JIM and SCT-PropSeg showed the highest between-scanner robustness (ICC consistency = 0.981 and 0.976, respectively). Reproducibility of segmentations between scan sessions was highest in Xinapse JIM and SCT-PropSeg segmentations (median SI ≥ 0.921), with a significant main effect of method (p < 0.001), but not of MR machine or subject group. In dataset B, SI with manual outlines did not differ between patients with or without cervical lesions for any of the segmentation methods (p > 0.176). However, there was an effect of method for both volumetric and voxel wise agreement of the segmentations (both p < 0.001). Highest volumetric and voxel wise agreement was obtained with Xinapse JIM (ICC absolute agreement = 0.940 and median SI = 0.962).ConclusionAlthough MUCCA is highly reproducible within a scanner for each individual measurement method, MUCCA differs between scanners and between methods. Cervical cord lesions do not affect MUCCA measurement performance.

C5-C6 Cervical Spinal Cord Cavernous Malformation Microsurgical Resection: 2-Dimensional Operative Video.

We describe the case of a previously healthy 44-yr-old female patient presenting with a sudden onset of numbness, paresthesias, and decreased sensation in her lower limbs. Physical examination revealed a decreased sensation to vibration and light touch in her lower extremities, primarily in the left limb. Impaired proprioception was also evident primarily in the left toe. Full strength with 2+ reflexes was observed in all extremities. Magnetic resonance imaging demonstrated an exophytic lesion in the posterior aspect of the cervical spinal cord at the C5-C6 level, with a hemosiderin halo, consistent with a cavernous malformation. Given the evidence of past hemorrhage and the location of the lesion, microsurgical intervention was indicated. A midline cervical C5-C6 laminectomy under neurophysiologic monitoring was performed, and complete resection of the lesion was achieved with mild improvement of the sensitive symptoms and no evidence of new motor deficits. Any microsurgical resection of a cervical spinal cord lesion can be technically difficult and adequate patient selection with evaluation of the accessibility to the lesion is key.1 Surgical resection of cavernous malformations in selected patients eliminates the risk of future hemorrhage and may achieve satisfactory outcomes comparable to patients who undergo conservative management.2 In the following video illustration, we narrate this operative case, and highlight the nuances of this approach. Patient consent was obtained for the submission of the video to this journal.

Cerebellopontine Angle Glioblastoma with Concurrent Spinal Cord Involvement: A Case Report and Review of Literature

Objective: To report a unique case of cerebellopontine angle glioblastoma with concurrent spinal cord involvement. Background: Glioblastoma (GBM) is the most common primary malignancy of the central nervous system (CNS), comprising 46.6% of all CNS malignancies. By anatomic location, cerebellopontine angle (CPA) GBMs are exceedingly rare. To our knowledge, the following case represents the tenth reported case of CPA GBM and the first with a corresponding spinal cord tumor on presentation. Methods: Retrospective chart review was conducted for a patient with CPA GBM. The patient consented to the publication of her diagnostic studies. Result: A 43-year-old female presented with a 3-month history of right ear hearing loss. Brainmagnetic resonance imaging (MRI) demonstrated a right CPA mass as well as a cervical spinal cord mass of unknown histology. Pathology showed GBM, IDH wildtype and negative for the H3 K27M mutation, while the cervical spinal cord lesion was not amenable to biopsy. She received proton beam therapy with 60 Gy to the GBM and 50.4 Gy to the spinal cord tumor in 30 fractions each with concurrent Temozolomide. She received 2 cycles of adjuvant Temozolomide prior to her demise due to progressive disease. Conclusion: There are four possible origins of CPA glioblastoma: the cerebellum, brainstem, root entry zone of cranial nerve VIII, and heterotopic glial cells of the leptomeninges. Prognosis does not appear to depend on tumor origin. Outcomes are likely optimized by maximal safe resection followed by radiation and concurrent Temozolomide. Spinal cord involvement of malignant tumors can significantly adversely affect survival outcomes in such patients.

Missed diagnosis of chronic inflammatory demyelinating polyneuropathy in a patient with cervical myelopathy due to ossification of posterior longitudinal ligament.

In the current study, we report a missed diagnosis of combined chronic inflammatory demyelinating polyneuropathy (CIDP) in a patient with a cervical spinal cord lesion. At 3.5 months after the onset of symptoms, a 60-year-old female with mild motor weakness and significant weight loss underwent a surgical operation for decompression of the cervical spinal cord. However, her motor weakness was severely aggravated despite the surgical treatment, and she could not walk independently at 10 months after symptom onset. Based on the results of electrophysiological and cerebrospinal fluid tests, we diagnosed her with CIDP. Considering her medical history and the results of our evaluations, we think our patient’s neurological symptoms before the surgical operation were attributed, at least in part, to CIDP. Our study shows that clinicians should consider the possibilities of other lesions in different areas even when patients have a definite lesion in the cervical spinal cord or cervical spine.

Where and When to Cut? Fluorescein Guidance for Brain Stem and Spinal Cord Tumor Surgery-Technical Note.

BACKGROUND Spinal cord and brain stem lesions require a judicious approach with an optimized trajectory due to a clustering of functions on their surfaces. Intraoperative mapping helps locate function. To confidently locate such lesions, neuronavigation alone lacks the desired accuracy and is of limited use in the spinal cord.OBJECTIVETo evaluate the clinical value of fluoresceins for initial delineation of such critically located lesions.METHODSWe evaluated fluorescein guidance in the surgical resection of lesions with blood-brain barrier disruption demonstrating contrast enhancement in magnet resonance imaging in the spinal cord and in the brain stem in 3 different patients. Two patients harbored a diffuse cervical and thoracic spinal cord lesion, respectively. Another patient suffered metastatic lesions in the brain stem and at the floor of the fourth ventricle. Low-dose fluorescein (4 mg/kg body weight) was applied after anesthesia induction and visualized using the Zeiss Pentero 900 Yellow560 filter (Carl Zeiss, Oberkochen, Germany).RESULTSFluorescein was helpful for locating lesions and for defining the best possible trajectory. During resection, however, we found unspecific propagation of fluorescein within the brain stem up to 6 mm within 3 h after application. As these lesions were otherwise distinguishable from surrounding tissue, monitoring resection was not an issue.CONCLUSIONFluorescein guidance is a feasible tool for defining surgical entry zones when aiming for surgical removal of spinal cord and brain stem lesions. Unselective fluorescein extravasation cautions against using such methodology for monitoring completeness of resection. Providing the right timing, a window of pseudoselectivity could increase fluoresceins’ clinical value in these cases.

Familial multiple sclerosis in Greece: Distinct clinical and imaging characteristics in comparison with the sporadic disease

ObjectiveFew studies are available worldwide concerning clinical, imaging and genetic/immunogenetic profile of familial multiple sclerosis (fMS). Recent but not systematic data concerning fMS, without direct comparison to sporadic MS (sMS) drove our aim towards further research in the field, given the total lack of information for the Greek population as well. Thus, in this case-control study we examined the clinical and imaging characteristics of 102 fMS-patients, compared to 282 patients suffering sMS. Patients and methodsPatients recruited underwent medical interview (demographic, clinical and family history data collected). They were also assessed for disability and their MRI-scans were analyzed for lesion distribution. Statistical analyses were performed using SPSS v.21.0 software. Results49% of unrelated fMS cases had at least one 1st degree relative affected, while the rest had also at least one relative with MS, 3rd degree or closer. Only the former subgroup (1st degree relative) and not the entire fMS sample, had significantly younger age at onset (AAO) compared to sMS cases (mean AAO 28.08 vs 31.33 years, p = 0.036). AAO anticipation was noted in younger generation fMS patients (mean AAO 24.67 years in younger generation vs 37 years in older generation, p = 0.001). With regard to our MRI findings, subcortical lesions were less frequent in fMS (71% in fMS vs 81.9% in sMS patients, p = 0.028), whereas cervical cord lesions more frequent (93% in fMS vs 79.9% in sMS patients, p = 0.033, only in the 1st degree relative subgroup). Double vision was a less common first symptom in fMS (4.1% in fMS vs 14.8% in sMS patients, p = 0.005). 1st degree relatives of fMS patients were more often diagnosed with Hashimoto’s (8.9% in fMS relatives vs 3.3% in sMS relatives, p = 0.033). ConclusionYounger AAO and different lesion distribution in brain and possibly spinal cord was observed in fMS in comparison to sMS patients. The hypothesis of increased genetic burden in fMS could offer some explanation for these differences, which needs though further validation as a next step, through genetic/immunogenetic testing in larger cohorts, of different ethnic groups.

Phase sensitive reconstruction of T1-weighted inversion recovery in the evaluation of the cervical cord lesions in Multiple Sclerosis; is it similarly eligible in 1.5 T magnet fields?

BackgroundIn primary studies with 3 T Magnets, phase sensitive reconstruction of T1-weighted inversion recovery (PSIR) have showed ability to depict the cervical multiple sclerosis (MS) lesions some of which may not be detected by short tau inversion recovery (STIR). Regarding to more availability of 1.5 T MRI, this study was designed to evaluate the eligibility of PSIR in 1.5 T for detection of spinal cord MS lesions. MethodIn a study between September 2016 till March 2017 the patients with proven diagnosis of MS enrolled to the study. The standard protocol (sagittal STIR and T2W FSE and axial T2W FSE) as well as sagittal PSIR sequences were performed using a 1.5 T magnet. The images were studied and the lesions were localized and recorded as sharp or faint on each sequence. ResultsOf 25 patients (22 females and 3 males, with mean age of 33.5 ± 9.8 years and mean disease duration of 5.4 ± 3.9 years) 69 lesions in STIR, 53 lesions in T2W FSE, 47 lesions in Magnitude reconstruction of PSIR (Magnitude), and 30 lesions in phase sensitive (real) reconstruction PSIR were detected. A Wilcoxon signed-rank test showed STIR has a statistically significant higher detection rate of the plaques rather than other three sequences. (STIR and T2W FSE, Z = −4.000, p < 0.0001, STIR and Magnitude, Z = −4.690, p < 0.0001, STIR and PSIR, Z = −6.245, p = 0.002) Also, STIR had a statistically significant superiority in the boundary definition of the plaques rather than other three sequences. ConclusionThis study shows that in the setting of a 1.5 T magnet field, STIR significantly has a superiority over both of the PSIR reconstructions (i.e. real and magnitude) for the detection as well as the boundary definition of the cervical cord lesions of MS. These results have a good relevance to clinical practice by using MRI scanners and sequences routinely available, however, it is discrepant with other reports performed by 3 T Magnet fields.

Cervical Cord T1-weighted Hypointense Lesions at MR Imaging in Multiple Sclerosis: Relationship to Cord Atrophy and Disability.

Purpose To characterize the spatial distribution of cervical cord T1-weighted hypointense lesions in patients with multiple sclerosis (MS) and analyze their association with cord atrophy and disability. Materials and Methods For this prospective study that took place between 2014 and 2016, 3.0-T high-resolution T1-weighted cervical cord magnetic resonance (MR) images and clinical evaluations were obtained from 82 patients with relapsing-remitting MS (RRMS), 33 patients with secondary progressive MS (SPMS), 25 patients with primary progressive MS (PPMS), and 35 sex-matched healthy control participants. Hypointense cord lesions on T1-weighted imaging were identified and corresponding lesion masks were produced. A semiautomatic method on the basis of active surfaces was used to perform voxel-wise assessment (by using statistical parametric mapping and full factorial models) of T1-weighted hypointense lesion distribution and cord atrophy. Results T1-weighted hypointense cervical cord lesions were detected in 122 of 140 (87.1%) patients with MS. Lesions were preferentially located in the posterior (P = .01) and upper (P < .001) cervical cord. Lesion extent at C1/C2 and C5 was higher in patient with SPMS versus RRMS, and patients with PPMS versus RRMS and SPMS (P value range, <.001 to .05). Cord atrophy at upper cervical levels was found in patients with MS compared with control participants, especially in progressive MS (P value range, <.001 to .04). Partial overlap (r = 0.66; P < .001) occurred between regions with T1-weighted hypointense cord lesions and atrophy. Cord atrophy (r value range, -0.24 to -0.48; P < .001) and T1-weighted hypointense cord lesion extent (r value range, 0.36-0.42; P < .001) were correlated with clinical disability. Conclusion Hypointense lesions at T1-weighted imaging were observed in the cervical spinal cord of the majority of patients with MS and more widespread in progressive than in relapsing MS phenotypes. Both T1-weighted hypointense cord lesions and atrophy correlated with patient clinical disability.

Occipital neuralgia associates with high cervical spinal cord lesions in idiopathic inflammatory demyelinating disease

The association of trigeminal neuralgia with pontine lesions has been well documented in multiple sclerosis, and we tested the hypothesis that occipital neuralgia in multiple sclerosis is associated with high cervical spinal cord lesions. We retrospectively reviewed the records of 29 patients diagnosed with both occipital neuralgia and demyelinating disease by a neurologist from January 2001 to December 2014. We collected data on demographics, clinical findings, presence of C2-3 demyelinating lesions, and treatment responses. The patients with both occipital neuralgia and multiple sclerosis were typically female (76%) and had a later onset (age > 40) of occipital neuralgia (72%). Eighteen patients (64%) had the presence of C2-3 lesions and the majority had unilateral symptoms (83%) or episodic pain (78%). All patients with documented sensory loss (3/3) had C2-3 lesions. Most patients with progressive multiple sclerosis (6/8) had C2-3 lesions. Of the eight patients with C2-3 lesions and imaging at onset of occipital neuralgia, five (62.5%) had evidence of active demyelination. None of the patients with progressive multiple sclerosis (3/3) responded to occipital nerve blocks or high dose intravenous steroids, whereas all of the other phenotypes with long term follow-up (eight patients) had good responses. A cervical spine MRI should be considered in all patients presenting with occipital neuralgia. In patients with multiple sclerosis, clinical features in occipital neuralgia that were predictive of the presence of a C2-3 lesion were unilateral episodic symptoms, sensory loss, later onset of occipital neuralgia, and progressive multiple sclerosis phenotype. Clinical phenotype predicted response to treatment.

Characteristics of neuromyelitis optica spectrum disorder associated with the area postrema

Objective: To evaluate the clinical characteristics and the corresponding MRI and laboratory findings in patients with neuromyelitis optica spectrum disorder (NMOSD) associated with area postrema (AP). Methods: The study was a retrospective analysis of data from 120 NMOSD patients, and 18 cases were with AP out of these patients, The clinical presentation, MRI changes, serological markers and treatment outcome were reported. Results: AP occurred in 18 patients (15%, 18/120). AP was the onset symptom in 14 (14/18) patients and 3 days to 7 months (median 40 days) later, optic neuritis or myelitis was involved. One patient presented AP after optic neuritis. Three patients (3/18) had AP and myelitis or optic neuritis simultaneously. AP symptom presented as intractable nausea and vomiting, hiccups. Compared to the patients without AP (n=102), the patients with AP (n=18) had shorter duration and fewer numbers of optic neuritis(P<0.05). There was no statistical difference in sex, onset age, course of disease (relapsing or monophasic) and EDSS scores (P>0.05). The MRI revealed flake or linear lesions in medulla. Twelve patients had cervical cord lesions extending to medulla lesions (12/18). Eleven patients had long cord lesions extending more than 3 spinal cords. The AQP4-antibody did not differ in patients with or without AP (14/18 vs 75/102). The symptom of AP was successfully relieved with methylprednisolone. Conclusion: AP symptoms/signs are common in patients with NMOSD. Vomiting and hiccups can be the first symptoms. The medulla lesions and the lesions extending to upper cervical cord are unique to NMOSD. Awareness of AP presentations is helpful for early diagnosis and proper treatment to prevent further disability.

Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms in NMOSD.

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune demyelinating disorder of the CNS that frequently affects brainstem functions.1 Trigeminal neuralgia occurs in 2.5% of patients with NMOSD1; however, the occurrence of trigeminal autonomic cephalalgia (TAC) is rarely reported.2,3 Here, we describe a case of NMOSD with anti–aquaporin-4 (AQP4) antibodies who had a relapse with brainstem and cervical spinal cord lesions manifesting as short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA), a rare form of TAC.

Cervical spinal cord atrophy: An early marker of progressive MS onset.

ObjectiveTo assess whether cervical spinal cord atrophy heralds the onset of progressive MS.MethodsWe studied 34 individuals with radiologically isolated syndrome (RIS) and 31 patients with relapsing-remitting MS (RRMS) age matched to 25 patients within a year of onset of secondary progressive MS (SPMS). Two raters independently measured (twice per rater) the cervical spinal cord average segmental area (CASA) (mm2) of axial T2-weighted images between C2 and C7 landmarks. The midsagittal T2-weighted image from the end of C2 to the end of C7 vertebra was used to measure the cervical spine (c-spine) length (mm). Sex, age at cervical MRI, number and location of cervical spinal cord lesions, c-spine length, and diagnoses were analyzed against the outcome measures of CASA and C2 and C7 slice segmental areas.ResultsIntrarater and interrater agreement was excellent (intraclass correlation coefficient >0.97). The CASA area (p = 0.03) and C7 area (p = 0.002) were smaller in SPMS compared with RRMS. The C2 area (p = 0.027), CASA (p = 0.004), and C7 area (p = 0.003) were smaller in SPMS compared with RIS. The C2 area did not differ between SPMS and RRMS (p = 0.09). The C2 area (p = 0.349), CASA (p = 0.136), and C7 area (p = 0.228) did not differ between RIS and MS (SPMS and RRMS combined). In the multivariable model, ≥2 cervical spinal cord lesions were associated with the C2 area (p = 0.008), CASA (p = 0.009), and C7 area independent of disease course (p = 0.017). Progressive disease course was associated with the C7 area independent of the cervical spinal cord lesion number (p = 0.004).ConclusionCervical spinal cord atrophy is evident at the onset of progressive MS and seems partially independent of the number of cervical spinal cord lesions.Classification of evidenceThis study provides Class III evidence that MRI cervical spinal cord atrophy distinguishes patients at the onset of progressive MS from those with RIS and RRMS.

C8 radiculopathy mistakenly diagnosed as cervical cord lesion: A case report

C8 radiculopathy mistakenly diagnosed as cervical cord lesion: A case report

Respiratory Dysfunction in Spinal Cord Injury: Physiologic Changes and Clinically Relevant Therapeutic Applications

Spinal cord injury (SCI) can result in serious respiratory compromise, impaired cough ability and respiratory failure. Complications include atelectasis and pneumonia. Respiratory failure is the primary cause of morbidity and mortality in high cervical cord injuries. Various methods have been used to assist coughing in SCI, including manual and mechanical techniques. Physical therapists can apply certain exercises and maneuvers to augment tidal breathing and expiratory effort, such as respiratory muscle training. For patients with vital capacities <10 to 15 mL/ kg, noninvasive methods such as abdominal binding, the pneumobelt, and face mask-applied ventilators are used to maintain adequate respiration. Phrenic nerve and diaphragmatic pacing provide increased patient mobility, comfort and lower health care costs; breathing pacemakers have increased survival and improved quality of life in individuals with upper cervical cord and brain stem lesions. Tracheostomy should be used only for those patients that have severe bulbar impairment and cannot successfully use airway clearance methods. Even patients with tracheostomyassisted ventilation can be eventually weaned off respirators, provided they meet criteria for spontaneous breathing. Peak expiratory flows should exceed 160 L/m to assure expulsion of airway secretions and the negative inspiratory pressure should exceed -20 cm H2O (variables measured with the tube cuff inflated) before the patient is decannulated. Appropriate vaccinations should be provided for any individual with compromised respiratory function, particularly with regularly scheduled influenza and pneumococcal pneumonia vaccines. Management of the physically impaired patient can be a major challenge for family, leading to adverse physical and psychological consequences. Long-term management requires a multidisciplinary approach that includes respiratory, physical and occupational therapists, nutritionists, social workers, psychologists, and home health agencies, all of whom contribute to key aspects of maintaining optimum respiratory function. Life satisfaction is a major consideration in this group of individuals, but it may have a more positive outlook than one would think in someone with significant physical and psychological challenges.

Depolarization and electrical stimulation enhance in vitro and in vivo sensory axon growth after spinal cord injury

Activity dependent plasticity is a key mechanism for the central nervous system (CNS) to adapt to its environment. Whether neuronal activity also influences axonal regeneration in the injured CNS, and whether electrical stimulation (ES) can activate regenerative programs in the injured CNS remains incompletely understood. Using KCl-induced depolarization, in vivo ES followed by ex-vivo neurite growth assays and ES after spinal cord lesions and cell grafting, we aimed to identify parameters important for ES-enhanced neurite growth and axonal regeneration. Using cultures of sensory neurons, neurite growth was analyzed after KCl-induced depolarization for 1-72h. Increased neurite growth was detected after short-term stimulation and after longer stimulation if a sufficient delay between stimulation and growth measurements was provided. After in vivo ES (20Hz, 2× motor threshold, 0.2ms, 1h) of the intact sciatic nerve in adult Fischer344 rats, sensory neurons showed a 2-fold increase in in vitro neurite length one week later compared to sham animals, an effect not observed one day after ES. Longer ES (7h) and repeated ES (7days, 1h each) also increased growth by 56–67% one week later, but provided no additional benefit. In vivo growth of dorsal column sensory axons into a graft of bone marrow stromal cells 4weeks after a cervical spinal cord lesion was also enhanced with a single post-injury 1h ES of the intact sciatic nerve and was also observed after repeated ES without inducing pain-like behavior. While ES did not result in sensory functional recovery, our data indicate that ES has time-dependent influences on the regenerative capacity of sensory neurons and might further enhance axonal regeneration in combinatorial approaches after SCI.

O160 The role of brainstem in syncope development

Objectives To investigate the role of brainstem in the development of vasovagal syncope. Methods Eighty-six multiple sclerosis (MS) patients were enrolled (61 females, mean age 32.01 ± 7.94). In all patients head-up tilt table test ocular and cervical vestibular evoked myogenic potentials (VEMPs) and brain and cervical spinal cord MRIs were performed. Additionally in 16 patients with syncope (8 females, mean age 28.43 ± 11.03,) VEMPs were performed. Results Syncope developed in 18 (20.9%) MS patients. Seventeen (94.4%) MS patients with syncope did not have brainstem and cervical spinal cord lesions (Chi square = 5.217, p = 0.022). Conduction block on VEMP was evident in 17 patients (19.8%). Only 2 out of 18 patients with syncope (11.1%) had conduction block on VEMP. A model was developed that predicted that only MS patients who do not have conduction blocks on VEMP and brainstem and cervical spinal cord MR lesions could develop syncope. The model accurately detected 83.3% of patients with syncope (15 of 18); Chi-Square = 4.980, p = 0.026. A significant difference in ocular VEMP amplitudes was found between MS patients with and without syncope and syncope patients ( p 0.001 ). Patients who developed syncope (regardless having or not MS), had significantly higher oVEMP amplitudes (10.21 ± 7.19 vs 7.85 ± 7.56, p = 0.034). Discussion Recent studies suggest that the initiation of syncope starts in the brainstem, and the purpose syncope is to salvage the brain’s blood supply. Conclusion Functional and structural integrity of the brainstem in MS are needed for syncope development. Significance Our results indicate the central role of the upper brainstem in the pathophysiology of syncope. This study was partially funded by the Installation Research project HRZZ UIP-11-2013-2622 of the Croatian Science Foundation.

Are midsagittal tissue bridges predictive of outcome after cervical spinal cord injury?

T2 -weighted scans provided data on the extent and dynamics of neuronal tissue damage and midsagittal tissue bridges at the epicenter of traumatic cervical spinal cord lesions in 24 subacute tetraplegic patients. At 1 month postinjury, smaller lesion area and midsagittal tissue bridges identified those patients with lower extremity evoked potentials and better clinical recovery. Wider midsagittal tissue bridges and smaller lesions at 1 month post-injury were associated with neurological and functional recovery at 1-year follow-up. Neuroimaging biomarkers of lesion size and midsagittal tissue bridges are potential outcome predictors and patient stratifiers in both subacute and chronic clinical trials. Ann Neurol 2017;81:740-748.

A large cervical spinal cord lesion in a patient with neurofibromatosis type 1: Multiple sclerosis plaque or hamartoma. (P3.161)

A large cervical spinal cord lesion in a patient with neurofibromatosis type 1: Multiple sclerosis plaque or hamartoma. (P3.161)