Changes In Neurological Status Research Articles

P.130 Endoscopic fenestration of trapped fourth ventricle

Background: Trapped fourth ventricle (TFV) is a rare entity that occurs when the fourth ventricle is obstructed and isolated from the normal cerebrospinal fluid (CSF) circulation. While not always symptomatic, TFV can lead to compression of the cerebellum and brainstem, with potential for serious consequences. Treatment of TFV can be challenging, with options including CSF diversion via shunts versus open or endoscopic fenestrations. In this report, we describe a case of TFV that was managed endoscopically. Methods: A seven-year-old girl with a history of myelomeningocele and hydrocephalus, presented with a change in neurological status. Imaging of the brain and spine showed syringomyelia, markedly dilated ventricles, and a TFV. An endoscopic approach was used to fenestrate the wall of the fourth ventricle. Results: While there was an early favorable outcome, the first fenestration closed over within one month, requiring a repeat endoscopic fenestration. Both procedures were complicated by transient seizures, requiring a pediatric intensive care unit (PICU) admission after the second intervention. Pre- and post-operative clinical and diagnostic imaging findings are reported. Conclusions: Endoscopic fenestration can be an effective treatment option for management of TFV. The patient, family, and treating team should be prepared to deal with acute peri-operative complications that may require PICU management.

Exploring the role of in-patient magnetic resonance imaging use among admitted ischemic stroke patients in improving patient outcomes and reducing healthcare resource utilization.

Despite the diagnostic and etiological significance of in-patient MRI in ischemic stroke (IS), its utilization is considered resource-intensive, expensive, and thus limiting feasibility and relevance. This study investigated the utilization of in-patient MRI for IS patients and its impact on patient and healthcare resource utilization outcomes. This retrospective registry-based study analyzed 1,956 IS patients admitted to Halifax's QEII Health Centre between 2015 and 2019. Firstly, temporal trends of MRI and other neuroimaging utilization were evaluated. Secondly, we categorized the cohort into two groups (MRI vs. No MRI; in addition to a non-contrast CT) and investigated adjusted differences in patient outcomes at admission, discharge, and post-discharge using logistic regression. Additionally, we analyzed healthcare resource utilization using Poisson log-linear regression. Furthermore, patient outcomes significantly associated with MRI use underwent subgroup analysis for stroke severity (mild stroke including transient ischemic attack vs. moderate and severe stroke) and any acute stage treatment (thrombolytic or thrombectomy or both vs. no treatment) subgroups, while using an age and sex-adjusted logistic regression model. MRI was used in 40.5% patients; non-contrast CT in 99.3%, CT angiogram in 61.8%, and CT perfusion in 50.3%. Higher MRI utilization was associated with male sex, younger age, mild stroke, wake-up stroke, and no thrombolytic or thrombectomy treatment. MRI use was independently associated with lower in-hospital mortality (adjusted OR, 0.23; 95% CI, 0.15-0.36), lower symptomatic neurological status changes (0.64; 0.43-0.94), higher home discharge (1.32; 1.07-1.63), good functional outcomes at discharge (mRS score 0-2) (1.38; 1.11-1.72), lower 30-day stroke re-admission rates (0.48; 0.26-0.89), shorter hospital stays (regression coefficient, 0.92; 95% CI, 0.90-0.94), and reduced direct costs of hospitalization (0.90; 0.89-0.91). Subgroup analysis revealed significantly positive association of MRI use with most patient outcomes in moderate and severe strokes subgroup and non-acutely treated subgroup. Conversely, outcomes in mild strokes (including TIAs) subgroup and acute treatment subgroup were comparable regardless of MRI use. A substantial proportion of admitted IS patients underwent MRI, and MRI use was associated with improved patient outcomes and reduced healthcare resource utilization. Considering the multifactorial nature of IS patient outcomes, further randomized controlled trials are suggested to investigate the role of increased MRI utilization in optimizing in-patient IS management.

Changes in neurologic status after traumatic brain injury in the Resuscitation Outcomes Consortium Hypertonic Saline trial.

Traumatic brain injury (TBI) is an important public health problem resulting in significant death and disability. Emergency medical services (EMS) personnel often provide initial treatment for TBI, but only limited data describe the long-term course and outcomes of this care. We sought to characterize changes in neurologic status among adults with TBI patients enrolled in the Resuscitation Outcomes Consortium Hypertonic Saline (ROC-HS) trial. We used data from the TBI cohort of the ROC-HS trial. The trial included adults with TBI, with Glasgow Coma Scale (GCS) ≤8, and excluded those with shock (systolic blood pressure [SBP] ≤70 or SBP 71-90 with a heart rate [HR] ≥108). The primary outcome was Glasgow Outcome Scale-Extended (GOS-E; 1=dead, 8=no disability) determined at (a) hospital discharge and (b) 6-month follow-up. We assessed changes in GOS-E between hospital discharge and 6-month follow-up using descriptive statistics and Sankey graphs. Among 1279 TBI included in the analysis, GOS-E categories at hospital discharge were as follows: favorable (GOS-E 5-8) 220 (17.2%), unfavorable (GOS-E 2-4) 664 (51.9%), dead (GOS-E 1) 321 (25.1%), and missing 74 (5.8%). GOS-E categories at 6-month follow-up were as follows: favorable 459 (35.9%), unfavorable 279 (21.8%), dead 346 (27.1%), and missing 195 (15.2%). Among initial TBI survivors with complete GOS-E,>96% followed one of three neurologic recovery patterns: (1) favorable to favorable (20.0%), (2) unfavorable to favorable (40.3%), and (3) unfavorable to unfavorable (36.0%). Few patients deteriorated from favorable to unfavorable neurologic status, and there were few additional deaths. Among TBI receiving initial prehospital care in the ROC-HS trial, changes in 6-month neurologic status followed distinct patterns. Among TBI with unfavorable neurologic status at hospital discharge, almost half improved to favorable neurologic status at 6 months. Among those with favorable neurologic status at discharge, very few worsened or died at 6 months. These findings have important implications for TBI clinical care, research, and trial design.

Impact of early MRI in ischemic strokes beyond hyper-acute stage to improve patient outcomes, enable early discharge, and realize cost savings

BackgroundEarly in-patient MR Imaging may assist in identifying stroke etiology, facilitating prompt secondary prevention for ischemic strokes (IS), and potentially enhancing patient outcomes. This study explores the impact of early in patient MRI on IS patient outcomes and healthcare resource use beyond the hyper-acute stage. MethodsIn this retrospective registry-based study, 771 admitted transient ischemic attack (TIA) and IS patients at Halifax's QEII Health Centre from 2015 to 2019 underwent in-patient MRI. Cohort was categorized into two groups based on MRI timing: early (within 48 h) and late. Logistic regression and Poisson log-linear models, adjusted for age, sex, stroke severity, acute stroke protocol (ASP) activation, thrombolytic, and thrombectomy, were employed to examine in-hospital, discharge, post-discharge, and healthcare resource utilization outcomes. ResultsAmong the cohort, 39.6 % received early in-patient MRI. ASP activation and TIA were associated with a higher likelihood of receiving early MRI. Early MRI was independently associated with a lower rate of symptomatic changes in neurological status during hospitalization (adjusted odds ratio [OR], 0.42; 95 % confidence interval [CI], 0.20–0.88), higher odds of good functional outcomes at discharge (1.55; 1.11–2.16), lower rate of non-home discharge (0.65; 0.46–0.91), shorter length of stay (regression coefficient, 0.93; 95 % CI, 0.89–0.97), and reduced direct cost of hospitalization (0.77; 0.75–0.79). ConclusionEarly in-patient MRI utilization in IS patients post-hyper-acute stage was independently associated with improved patient outcomes and decreased healthcare resource utilization, underscoring the potential benefits of early MRI during in-patient management of IS. Further research, including randomized controlled trials, is warranted to validate these findings.

Clinical effect of a modified superficial temporal artery-middle cerebral artery bypass surgery in Moyamoya disease treatment

BackgroundCerebral extracranial-intracranial (EC-IC) revascularization technique (superficial temporal artery-middle cerebral artery (STA-MCA) bypass grafting) has become the preferred surgical method for the treatment of Moyamoya disease (MMD). We attempted to completely free the two branches of the superficial temporal artery without disconnection. Extracranial and intracranial blood flow reconstruction were then modified by selectively performing a direct bypass technique on one branch and a patch fusion technique on the other of the STA based on the blood flow and the vascular diameter of the intracranial surface blood vessels.MethodsA series of modified STA-MCA bypass surgeries performed consecutively between March 2022 and March 2023 were reviewed and compared to conventional combined bypass surgeries performed during the same period. The following information was collected from all enrolled patients: demographic characteristics, clinical symptoms, and preoperative and postoperative imaging, including Suzuki stage and Matsushima grade. The modified Rankin scale (mRS) was used to assess the changes in neurological status before and after surgery.ResultsA total of 41 patients with Moyamoya disease (MMD) who underwent cerebral revascularization were included in this study, of which 30 were conventional revascularization and 11 were modified revascularization. The mean age was 49.91 years, and 18 (43.9%) of the patients were women. The modified group had a lower incidence of cerebral hyperperfusion syndrome (18.2%) than the conventional group (23.3%). After at least 3 months of follow-up, the bypass patency rate remained 100% in the modified group and 93.3% in the conventional group. All patients in the modified group achieved a better Matsushima grade (A + B), with six (54.5%) having an A and five (45.5%) having a B. In contrast, four patients (13.3%) in the conventional group had a Matsushima grade of C. In all, 72.8% of the modified group had postoperative mRS scores of 0 and 1, which was higher than that of the traditional group (63.3%).ConclusionThe improved STA-MCA bypass could provide blood flow to multiple cerebral ischemic areas, reduce excessive blood perfusion, and ensure blood supply to the scalp, with lower complications and better clinical benefits than the traditional combined bypass.

C6 (Clinical Case) A 5-Year-Old with Headbanging and Hemiparesis

Abstract Introduction/Background A 5-year-old boy had a medical history of Phelan-McDermid syndrome; and with that associated autism spectrum disorder; severe, medication-resistant headbanging; and type 1 diabetes. He presented to community hospital with acute onset inability to walk, irritability, and vomiting. Case Description On examination he had left arm weakness and truncal ataxia. CT head identified a left cerebellar infarction. He was transferred to the local children’s hospital, and CT angiogram showed left PICA proximal occlusion. Due to diagnostic delay, the infarct was not amenable to endovascular intervention. Initial management was neuroprotective care, and given his history of headbanging and the risk of further trauma, only ASA monotherapy. MR brain visualized a left vertebral artery dissection, the stroke’s likely cause. Other causes were ruled out with normal echocardiogram and thrombophilia work-up, including antiphospholipid panel. Genetic analysis was negative for connective tissue diseases, bleeding or clotting disorders. On day 5 of admission, he acutely developed worsened left arm weakness and inability to bear weight. Repeat brain imaging showed new bilateral medial thalamic infarcts and diffusion restriction within the right putamen. Given this progression, despite the risk of bleeding, heparin was initiated. On day 9, repeat CT head identified a new lacunar infarct. On day 14, repeat MRI confirmed clinical stability, and he was switched from heparin to enoxaparin. After 27 days, he was discharged for home-based rehabilitation. His three-month follow-up MRI was stable, and anticoagulation was discontinued, while he remained on ASA only. Discussion There is no known association between Phelan-McDermid syndrome and cerebrovascular diseases. However, self-injurious behaviour, such as head banging, is not uncommon in the paediatric population, particularly among neurodiverse patients. These behaviours, in and of themselves, can cause significant injury and morbidity. The case shows how severe headbanging may have caused vertebral artery dissection with thromboembolic consequences. As such, for patients who demonstrate self-injurious behaviour, it is important to counsel these patients and families on potential harms, and inform efforts to mitigate risk, where possible. In cases of acute change to neurological status, stroke should remain on the differential diagnosis, and brain imaging should be considered. Time to central imaging affects therapeutic opportunities, as exemplified in this case where, due to delays in obtaining imaging, endovascular therapy was not an option for the patient. Conclusion Many children engage in self-injurious behaviour that can, as in this case, cause devastating consequences. Clinicians should remain wary of change in neurologic status and have low thresholds for central nervous system imaging, especially for patients with non-verbal communication.

Neurological scoring and gait kinematics to assess functional outcome in an ovine model of ischaemic stroke.

Assessment of functional impairment following ischaemic stroke is essential to determine outcome and efficacy of intervention in both clinical patients and pre-clinical models. Although paradigms are well described for rodents, comparable methods for large animals, such as sheep, remain limited. This study aimed to develop methods to assess function in an ovine model of ischaemic stroke using composite neurological scoring and gait kinematics from motion capture. Merino sheep (n = 26) were anaesthetised and subjected to 2 hours middle cerebral artery occlusion. Animals underwent functional assessment at baseline (8-, 5-, and 1-day pre-stroke), and 3 days post-stroke. Neurological scoring was carried out to determine changes in neurological status. Ten infrared cameras measured the trajectories of 42 retro-reflective markers for calculation of gait kinematics. Magnetic resonance imaging (MRI) was performed at 3 days post-stroke to determine infarct volume. Intraclass Correlation Coefficients (ICC's) were used to assess the repeatability of neurological scoring and gait kinematics across baseline trials. The average of all baselines was used to compare changes in neurological scoring and kinematics at 3 days post-stroke. A principal component analysis (PCA) was performed to determine the relationship between neurological score, gait kinematics, and infarct volume post-stroke. Neurological scoring was moderately repeatable across baseline trials (ICC > 0.50) and detected marked impairment post-stroke (p < 0.05). Baseline gait measures showed moderate to good repeatability for the majority of assessed variables (ICC > 0.50). Following stroke, kinematic measures indicative of stroke deficit were detected including an increase in stance and stride duration (p < 0.05). MRI demonstrated infarction involving the cortex and/or thalamus (median 2.7 cm3, IQR 1.4 to 11.9). PCA produced two components, although association between variables was inconclusive. This study developed repeatable methods to assess function in sheep using composite scoring and gait kinematics, allowing for the evaluation of deficit 3 days post-stroke. Despite utility of each method independently, there was poor association observed between gait kinematics, composite scoring, and infarct volume on PCA. This suggests that each of these measures has discreet utility for the assessment of stroke deficit, and that multimodal approaches are necessary to comprehensively characterise functional impairment.

Neurological aspects of diagnosis and treatment of motor alalia

To analyze the causes of violations of expressive speech in children 4-5 years old, to assess changes in neurological status in children with motor alalia without and during treatment with Cellex. Two groups of patients were recruited: the main group (n=30; treatment; Cellex) and the control group (n=12; without Cellex). The drug was administered in the first half of the day by 1.0 ml subcutaneously, 10 days, daily. The patient's visit card was analyzed 4 times: before treatment, 10 days later, 1 and 2 months after the start of treatment. Statistical hypotheses were tested using the χ2 and Fisher criterions, the odds ratio (OR) and the 95% confidence interval (CI) OR were determined. In more than half of the cases, violations of the neurological status, the burden of the perinatal period, a decrease in cognitive tests, and a lack of fine motor skills were revealed. Left-handedness or two-handedness, overload of viewing or listening to gadgets from the age of up to a year, violations of opercular praxis were almost always noted. The effect of the drug Cellex on the «launch of speech» in children with motor alalia has been shown. It has been established that the drug is well tolerated, has no adverse side effects and has a positive effect on the «launch of speech». The progress of the dynamics of speech development, progress in play and cognitive activity was observed in all children of the main group. The use of the drug Cellex can be effective in the treatment of children with motor alalia.

Abstract 226: Long-term Trajectory Of Neurologic Outcome After Severe Traumatic Brain Injury

Objective : Little is known about the time-based trajectories of neurologic recovery after traumatic brain injury (TBI). We sought to determine long-term changes in neurologic status after TBI. Methods: Data source: Resuscitation Outcomes Consortium Hypertonic Saline TBI Trial. Included: adult TBI, GCS≤8; Excluded: shock (SBP≤70, or SBP 71-90 with HR≥108). Primary outcome: Glasgow Outcome Scale-Extended (GOS-E; 1=dead, 8=no disability) determined at: a) hospital discharge and b) 6-months. We analyzed changes in GOS-E between hospital discharge and 6-months using Sankey graphs and the Wilcoxon signed-rank test. We repeated the analysis for the high acuity subset of patients undergoing EMS advanced airway insertion. Results: Among 1,282 TBI, GOS-E at discharge was: dead (GOS-E 1) n=321 (25.0%), unfavorable (2-4) n=664 (51.8%), favorable (5-8) n=220 (17.2%), missing n=77 (6.0%; Figure). GOS-E at 6-months was: dead n=346 (27.0%), unfavorable n=282 (22.0%), favorable n=459 (35.8%), missing n=195 (15.2%). While 7 of 220 (3.2%) with favorable GOS-E at discharge worsened at 6 months (unfavorable or died), 300 of 664 (45.2%) with unfavorable GOS-E improved to favorable at 6 months (Wilcoxon signed-rank for GOS-E change p&lt;0.0001). In the EMS advanced airway subset (n=774), 2 of 96 (7.1%) with favorable GOS-E at discharge worsened to unfavorable (or were dead) at 6 months, while 208 of 433 (48.0%) with unfavorable GOS-E improved to favorable at 6 months (Wilcoxon signed-rank for GOS-E change p&lt;0.0001). Conclusion: Among patients with TBI and unfavorable neurologic status at hospital discharge, almost half will progress to favorable neurologic status at 6 months. Very few TBI victims die or worsen to unfavorable neurologic status by the time of 6-month follow-up. Thus, assessment of long-term neurologic outcome should be considered for studies of TBI.

ODP589 Acute Hypercalcemic Crisis in an Elderly with Granulomatous Disease

Abstract We present here a case of an 81 year old female who developed changes in neurologic status due to elevated serum calcium levels in the setting of an elevated Vitamin D and low-normal parathyroid hormone level. Upon evaluation of PTH-independent causes of hypercalcemia, she was noted to have Tuberculosis. Anti-Koch's and steroids were initiated on top of vigorous hydration and diuresis which lead to improvement in the patient's serum calcium levels and clinical status. Tuberculosis rarely leads to clinically significant hypercalcemia. However, elderly patients remain predisposed due to advanced age, multiple comorbidities and polypharmacy. Hypercalcemia is a life threatening condition, but with prompt diagnosis and management it portends excellent outcomes. Presentation: No date and time listed

Correction of pediatric cervical kyphosis with standalone posterior approach-a single-center experience of seven cases.

To study clinical and radiological outcomes of pediatric cervical kyphosis correction with a standaloneposterior cervical approach. Cervical spine kyphotic deformity in pediatric age group is a distinct entity and themanagement is challenging. Pediatric cervical kyphosis is less often encountered, and literature is sparse with onlyfew case series. Management algorithms are devised keeping the flexibility of the deformity at the core of decisionmaking. Circumferential fusion is mostly recommended for non-flexible (rigid) kyphosis. Authors present a single center retrospective analysis of cases of pediatric cervical kyphosis managed bya standalone posterior approach. Pre- and post-operative clinical and radiological parameters were recorded andanalyzed. Changes in neurological status, kyphosis correction and bony fusion were assessed. Surgical andimplant related complications were noted. Seven cases (6 male, 1 female) were included. Mean age was 13.9±2.9 years, ranging from 8-17 years.Etiology was traumatic in 2 cases, developmental in 2, and syndromic, Hirayama disease and post-laminectomy in1 case each. Mean kyphosis correction was 36.80±19.30 (87%±21%) with a mean pre-operative kyphosis angle of37.80±15.30 and mean immediate post-operative kyphosis angle of 3.70±8.70. Mean hospital stay duration was10±6 days. Median follow-up duration was 36 months. Myelopathy improved in 5 cases at last follow-up. Six casesdemonstrated bony fusion at a mean follow-up of 8.4±1.5 months. Significant immediate correction in pediatric cervical kyphosis may be achieved with a standaloneposterior approach with proper planning and technique in selected cases. Inserting pedicle screws at strategiclocations of implant construct offer better corrections and pull-out strength and maintain long-term stability resultingin higher arthrodesis rates. Larger studies with longer follow up are needed to further ascertain the role ofstandalone posterior cervical approaches in pediatric cervical kyphosis.

Effect of radiofrequency denervation on pain severity among patients with cervical, thoracic or lumbar spinal pain: A clinical retrospective study

BackgroundLow back pain is the leading cause of job-related disabilities. The zygapophyseal (facet) joint has been identified as a cause of spinal pain in 15%–45% of individuals. Radiofrequency ablation (RFA) to the facet joints of the lumbar, cervical and thoracic regions and discussion of the 2-year follow-up results will provide additional data and contribute to understanding the long-term effectiveness of RFA. MethodsPatients with cervical, thoracic or low back pain, not accompanied by radicular pain and without primary and/or metastatic disease in the spinal region during radiological evaluation were retrospectively analysed. A total of 1274 patients aged >18 years who had clinical follow-up for at least 1 year and had back pain for >6 months were included in the study. The RFA groups were compared within themselves before and after the application. Moreover, patients who received RFA were compared with those who did not receive RFA (controls). The visual analogue scale and quality-of-life scores of the patients were evaluated. Periodic clinical follow-ups revealed changes in neurological status. ResultsOf the 774 patients who underwent RFA, 156, 184 and 434 patients had pain in the cervical, thoracic and lumbar and lumbosacral regions, respectively. The control groups consisted of 108, 122 and 270 patients, respectively. No significant difference in any of the baseline demographic variables was observed between the groups (p > 0.05). A significant improvement was found in both visual analogue scale and quality-of-life scores when compared before and after RFA application within the groups. In addition, a significant improvement was found in the RFA group compared with the control group. ConclusionsAs far as we know, this is the first comparative study of RFA involving the cervical, thoracic and lumbar spinal regions. RFA made it possible to obtain satisfactory results in all three regions. With its increasing popularity and frequency of use, new indications for RFA may emerge.

Orthostatic Hypotension Management in Patients with Traumatic Cervical Myelopathy

Aim. To study the incidence and severity of orthostatic hypotension and develop a method for its correction in patients after spinal cord injury (SCI) at the cervical level. Material and мethods. The study included 120 patients after spinal cord injury at cervical level with tetraplegia C5–C8 motor levels since injury more than 1 year divided into 3 groups comparable in terms of demographic, neurological and functional parameters. The group 1 (control) received standard therapy (exercise therapy, modalities, ergotherapy, massage), the group 2 received standard therapy and permanent wearing of an abdominal bandage during the day, the group 3 received rehabilitation identical to the group 2 in conjunction with low-intensity laser therapy (reflex-segmental technique). Evaluation of the results was carried out at the beginning (T1), at the end (T2) after a 30-day rehabilitation course; in assessing the state of the ANS used heart rate variability, ABPM, tilt test, deep breathing test; the motor system was assessed using the international neurological assessment standard — ASIA Impairment Scale, the FIM motor subscale (FIMm). Results and discussion. The quantity of 35% of patients have orthostatic hypotension while subjective manifestations during the tilt test was seen only in 22% of patients. At the initial examination, there were no differences between the groups in terms of vegetative and functional status. There were no changes in neurological status in all groups, functional activity increased by 6 ± 5.4 points in the control group (FIMm), and 6 ± 4.6 and 7 ± 4.5 points in 2 and 3 groups, respectively without any the statistical differences between the groups (F = 0.51; p = 0.42) at the end of rehabilitation. There were positive changes in vegetative parameters in all groups, with the exception of the mean night systolic blood pressure (SBP) between the 1 and 2 groups. Intergroup comparison have shown positive changes in all vegetative parameters that was higher in the 2 and 3 groups: decreasing drop of SBP during tilt test was 4 ± 2.8. and 5 ± 3.2 mm Hg, increase in inspiratory- expiratory index (RRmax / RRmin) 0.5 ± 0.08 and 0.7 ± 0.10 units, increase in daytime mean SBP (ABPM) 5 ± 1.1 and 8 ± 1.4 mm Hg respectively in groups 2 and 3, against 2 ± 1.9 mm Hg. and 0.2 ± 0.05 units, 3 ± 0.9 mm Hg in the group 1. In group 3, the value and increase in RRmax / RRmin (1.21 ± 0.11; 1.23 ± 0.13; 1.27 ± 0.15, respectively, in 1, 2 and 3 groups), mean daytime SBP (105 ± 3; 108 ± 3; 110 ± 4 mm Hg, respectively in 1, 2, and 3 groups) was higher in the group 3. Conclusion. Orthostatic Hypotension (OH) occured in one third of patients in the late period after SCI at the cervical level, the method of OH management that included daytime abdominal bandage wearing and using low-intensity laser radiation (905 nm, 50 Hz) on the cardioreflex zones has shown its preliminary effectiveness.

COVID-19-Associated Encephalopathy-Case Series and Clinical Considerations.

Neurological manifestations of the SARS-CoV-2 infection are present in up to 80% of the affected patients. While the majority of them is benign, in certain patients, viral replication in the central nervous system results in a severe disruption in cognitive function as well as basic life functions. In this case series, the authors present a detailed description of the three SARS-CoV-2 infection cases, which were all complicated by severe encephalopathy. Consecutive neurological status changes were described for each patient with detailed imaging and clinical sequelae. In the discussion, the authors highlight similarities in the course of the disease in presented patients, as well as common features in test results. An effective causal treatment could not be introduced in any of the patients, nor could the progression of the central nervous system (CNS) damage be stopped. The authors hope that the experiences they gathered will help to accelerate the diagnostic and therapeutic process in other patients with COVID-19-associated encephalopathy and result in introducing an effective treatment.

Surgical prevention of progressive cerebral ischemia after ischemic stroke

To evaluate the effectiveness of carotid endarterectomy after ischemic stroke and to analyze postoperative neurological status. There were 120 patients with carotid artery stenosis complicated by chronic cerebrovascular insufficiency (CVI). Patients with CVI grade I-III were included in the first group (n=70), 50 patients had previous ischemic stroke (the second group). Age of patients was 61-89 years. All patients underwent unilateral carotid endarterectomy. Over 36-month follow-up period, postoperative stroke occurred in 5 (7.2%) and 9 (18.3%) patients in both groups, respectively. The combined end-point (stroke + mortality) was significantly less common in group I compared to group II (10 (14.5%) and 15 (30%) cases, p>0.05). Positive changes in neurological status were found in the 2nd group (relief of focal neurological deficit, symptoms of cerebrovascular insufficiency, no progression of vascular dementia). Barthel score increased from 74.3 to 92.8 after carotid endarterectomy in the 2nd group. Baseline FAB score <11 was observed in 9% of patients in the 1st group and 22% in the 2nd group. No progression of dementia was observed in long-term period. Carotid endarterectomy is effective in prevention of primary and recurrent stroke. Moreover, this procedure slows down progression of chronic cerebral ischemia and cognitive impairment.

Continuous Renal Replacement Therapy Using Membranes with Increased Adsorption Capacity in Patients with Septic Shock after Neurosurgical Interventions

Introduction. The combination of primary brain injury with cytokine storm and hemodynamic disturbance in septic shock leads to secondary brain damage and growing neurological deficit. Blood purification procedures can be considered as an additional option in the treatment of septic shock in this group of patients.Subjects and Methods. The study included 11 patients after neurosurgical interventions with septic shock and acute kidney injury who underwent continuous renal replacement therapy (CRRT) using membranes with increased adsorption capacity.Results. During CRRT there was a significant regression in severity of multiorgan dysfunction according to SOFA score, a decrease in the requirement for vasopressor support with norepinephrine, and a decrease in lactate blood level. In addition, after the end of the procedure, there was a significant decrease in procalcitonin blood level. Septic shock reversal was observed in 8/11 patients (72.7%). In 3/11 patients, neurological deficits regressed during the procedure.Conclusions. The results indicate the possibility of using CRRT with membranes with increased adsorption capacity in patients after neurosurgical interventions with septic shock. Changes in neurological status can be considered as an additional parameter for the effectiveness of therapy for septic shock in patients with primary brain injury.

P.145 Perceived Limits of Endovascular Treatment for Secondary Medium Vessel Occlusion Stroke

Background: Thrombus embolization during endovascular treatment (EVT) occurs in up to 9% of cases, making secondary medium-vessel occlusions (MeVOs) of particular interest to neurointerventionalists. We sought to gain insight into the current EVT approaches for secondary MeVO stroke in an international case-based survey as there are currently no clear recommendations for EVT in these patients. Methods: Participants were presented with three secondary MeVO cases, each consisting of three case-vignettes with changes in patient neurological status (improvement, no change, unable to assess). Clustered multivariable logistic regression analyses were used to assess factors influencing the decision to treat. Results: 366 physicians from 44 countries took part. The majority (54.1%) were in favor of EVT. Participants were more likely to treat occlusions in the anterior M2/3 (74.3%; risk ratio [RR]2.62, 95%CI:2.27-3.03) or A3 (59.7%; RR2.11, 95%CI:1.83-2.42) segment, compared to the M3/4 segment (28.3%;reference). Physicians were less likely to pursue EVT in patients with neurological improvement (49.9% versus 57.0%; RR0.88, 95%CI:0.83-0.92). Interventionalists and more experienced physicians were more likely to treat secondary MeVOs. Conclusions: Physician’s willingness to treat secondary MeVOs endovascularly is limited and varies per occlusion location and change in neurological status. More evidence on the safety and efficacy of EVT for secondary MeVO stroke is needed.

Perceived Limits of Endovascular Treatment for Secondary Medium-Vessel-Occlusion Stroke.

Thrombus embolization during mechanical thrombectomy occurs in up to 9% of cases, making secondary medium vessel occlusions of particular interest to neurointerventionalists. We sought to gain insight into the current endovascular treatment approaches for secondary medium vessel occlusion stroke in an international case-based survey because there are currently no clear recommendations for endovascular treatment in these patients. Survey participants were presented with 3 cases involving secondary medium vessel occlusions, each consisting of 3 case vignettes with changes in the patient's neurologic status (improvement, no change, unable to assess). Multivariable logistic regression analyses clustered by the respondent's identity were used to assess factors influencing the decision to treat. In total, 366 physicians (56 women, 308 men, 2 undisclosed) from 44 countries provided 3294 responses to 9 scenarios. Most (54.1%, 1782/3294) were in favor of endovascular treatment. Participants were more likely to treat occlusions in the anterior M2/3 (74.3%; risk ratio = 2.62; 95% CI, 2.27-3.03) or A3 (59.7%; risk ratio = 2.11; 95% CI, 1.83-2.42) segment compared with the M3/4 segment (28.3%; reference). Physicians were less likely to pursue endovascular treatment in patients who showed neurologic improvement than in patients with an unchanged neurologic deficit (49.9% versus 57.0% responses in favor of endovascular treatment, respectively; risk ratio = 0.88, 95% CI, 0.83-0.92). Interventionalists and more experienced physicians were more likely to treat secondary medium vessel occlusions. Physicians' willingness to treat secondary medium vessel occlusions endovascularly is limited and varies per occlusion location and change in neurologic status. More evidence on the safety and efficacy of endovascular treatment for secondary medium vessel occlusion stroke is needed.

PORTAL VENOUS GAS CAUSING CEREBRAL VENOUS AND PULMONARY ARTERY AIR EMBOLISM

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Venous air embolism can be caused by various mechanisms. Portal venous air as cause of venous air embolism has been reported very rarely in existing literature. CASE PRESENTATION: 67 y/o admitted to the hospital after episode of fall with hypoxia found to have right perinephric hematoma, multiple right rib fractures and bilateral transudative pleural effusion due to fluid overload. He also had MSSA bacteremia, getting treated with Cefazolin and HD catheter changed few weeks ago. Past medical history significant for ESRD on HD, DM II, CAD s/p CABG, A-fib on Coumadin, SSS s/p PPM, Bio prosthetic MVR, Infra-renal AAA, Chronic thrombocytopenia, HFpEF. Rapid response was called for acute change in neurological status and low BP of 84/58. He was noted to be alert but unresponsive even to pain, right gaze deviation, decorticate posturing. BP improved to 95/62 with 1L NS and was requiring 6LNC O2 supplementation to keep SpO2 > 90. Stroke Code was called, CTA Head and Neck showed air in multiple venous structures in neck, cavernous sinus, subarachnoid space and pulmonary artery. High flow oxygen was given and kept on Trendelenburg and left lateral position. CT Chest showed air in pulmonary artery and right atrium. CT Abdomen and Pelvis showed dilated small bowel with pneumatosis and extensive mesenteric venous and portal venous air. Surgery felt patient was poor surgical candidate. He went into sudden acute respiratory failure requiring intubation likely secondary to worsening air embolism. Due to poor prognosis and critical health family decided to transition to comfort care. DISCUSSION: Venous air embolism is usually caused by surgical procedure, trauma, central venous access and barotrauma. Pulmonary artery air embolism caused by portal venous air is rare with few case reported 1. Cerebral venous air embolism due to portal venous air has been reported only twice in literature 2,3. Based on literature review, there is no prior reported case of venous air embolism involving pulmonary artery and cerebral vein caused by portal venous air. CONCLUSIONS: Pulmonary artery air embolism and cerebral venous air embolism are rapidly fatal entity that could complicate patients with portal venous air, hence needs to be considered and recognized early. REFERENCE #1: Kamikado et al, Gas embolism caused by portal vein gas: case report and literature review. Case Rep Gastroenterology 2008;2:262-271 DOI: 10.1159/000146064 REFERENCE #2: Parikh et al, Gas embolic stroke secondary to bowel infarction. Journal of Stroke and Cerebrovascular Disease 2016;1;e1-e3 DOI: 10.1016 REFERENCE #3: Taydas et al, Retrograde cerebral air embolism in a patient with intestinal necrosis: a care report. Balkan Medical Journal 2017;34;371-373 DOI: 10.4274 DISCLOSURES: No relevant relationships by Woon Chong, source=Web Response No relevant relationships by Kiran Pokhrel, source=Web Response No relevant relationships by Gregory Wu, source=Web Response

Clinical applications of diffusion-weighted sequence in brain imaging: beyond stroke.

Diffusion-weighted imaging (DWI) is a well-established MRI sequence for diagnosing early stroke and provides therapeutic implications. However, DWI yields pertinent information in various other brain pathologies and helps establish a specific diagnosis and management of other central nervous system disorders. Some of these conditions can present with acute changes in neurological status and mimic stroke. This review will focus briefly on diffusion imaging techniques, followed by a more comprehensive description of the utility of DWI in common neurological entities beyond stroke.