Complete Neurological Recovery Research Articles

Neurologic injury after spinopelvic dissociation: Incidence, outcome, and predictors

BackgroundTraumatic spinopelvic dissociation is a rare injury pattern resulting in discontinuity between the spine and bony pelvis. This injury is associated with a known risk of neurologic compromise which can impact the clinical outcome of these patients. We sought to determine incidence and characteristics of neurologic injury, outcomes following treatment, and predictive factors for neurologic recovery. MethodsWe reviewed the clinical documentation and imaging of 270 patients with spinopelvic dissociation from three Level-1 trauma centers treated over a 20-year period. From this cohort, 137 patients fulfilled inclusion criteria with appropriate follow-up. Details surrounding patient presentation, incidence of neurologic injury, and outcome variables were collected for each injury. Neurologic injuries were categorized using the Gibbons criteria. Multivariate analysis was performed to assess for patient and injury factors predictive of neurologic injury and recovery. ResultsThe overall incidence of neurologic injury in spinopelvic dissociation injuries was 33% (45/137), with bowel and/or bladder dysfunction (n=16) being the most common presentation. Complete neurologic recovery was seen in 26 cases (58%) and two patients (4%) improved at least one Gibbon stage in clinical follow-up. The most common long-term neurologic sequela at final follow-up was radiculopathy (n=12, 9%). Increased kyphosis was found to be associated with neurologic injury (p=0.002), while location of transverse limb and Roy-Camille type were not predictive of neurologic injury (p=0.31 and p=0.07, respectively). There were no factors found to be predictive of neurologic recovery in this cohort. ConclusionNeurologic injury is commonly seen in patients with spinopelvic dissociation and complete neurologic recovery was seen in the majority of patients at final follow-up. When present, long term neurologic dysfunction is most commonly characterized by radiculopathy. While increasing kyphosis was shown to be associated with neurologic injury, no patient or injury factors were predictive of neurologic recovery.

Strategies of Advanced Airway Management in Out-of-Hospital Cardiac Arrest during Intra-Arrest Hypothermia: Insights from the PRINCESS Trial.

Trans-nasal evaporative cooling is an effective method to induce intra-arrest therapeutic hypothermia in out-of-hospital cardiac arrest (OHCA). The use of supraglottic airway devices (SGA) instead of endotracheal intubation may enable shorter time intervals to induce cooling. We aimed to study the outcomes in OHCA patients receiving endotracheal intubation (ETI) or a SGA during intra-arrest trans-nasal evaporative cooling. This is a pre-specified sub-study of the PRINCESS trial (NCT01400373) that included witnessed OHCA patients randomized during resuscitation to trans-nasal intra-arrest cooling vs. standard care followed by temperature control at 33 °C for 24 h. For this study, patients randomized to intra-arrest cooling were stratified according to the use of ETI vs. SGA prior to the induction of cooling. SGA was placed by paramedics in the first-tier ambulance or by physicians or anesthetic nurses in the second tier while ETI was performed only after the arrival of the second tier. Propensity score matching was used to adjust for differences at the baseline between the two groups. The primary outcome was survival with good neurological outcome, defined as cerebral performance category (CPC) 1-2 at 90 days. Secondary outcomes included time to place airway, overall survival at 90 days, survival with complete neurologic recovery (CPC 1) at 90 days and sustained return of spontaneous circulation (ROSC). Of the 343 patients randomized to the intervention arm (median age 64 years, 24% were women), 328 received intra-arrest cooling and had data on the airway method (<i>n</i> = 259 with ETI vs. <i>n</i> = 69 with SGA). Median time from the arrival of the first-tier ambulance to successful airway management was 8 min for ETI performed by second tier and 4 min for SGA performed by the first or second tier (<i>p</i> = 0.001). No significant differences in the probability of good neurological outcome (OR 1.43, 95% CI 0.64-3.01), overall survival (OR 1.26, 95% CI 0.57-2.55), full neurological recovery (OR 1.17, 95% CI 0.52-2.73) or sustained ROSC (OR 0.88, 95% CI 0.50-1.52) were observed between ETI and SGA. Among the OHCA patients treated with trans-nasal evaporative intra-arrest cooling, the use of SGA was associated with a significantly shorter time to airway management and with similar outcomes compared to ETI.

S2908 Liver Transplant for Management of Neurological Wilson Disease in a Patient With Preserved Liver Function

Introduction: The role of orthotopic liver transplant (OLT) solely for the management of neurological Wilson disease (WD) is unclear. We present a patient with WD who underwent OLT for neurological deterioration with compensated cirrhosis. Case Description/Methods: A 19-year-old male presented with three-month history of dysarthria, akinesia, and fine tremors. His past medical history was remarkable for unexplained splenomegaly and thrombocytopenia. He denied history and risk factors for liver disease. Physical exam showed slurred speech, bilateral hand tremors, spasticity of the lower extremities, and absence of Kayser-Fleischer ring. Labs were unremarkable, except for platelets of 79 k/uL. MRI brain showed bilateral, symmetric hyper-intensity in the basal ganglia, lateral thalami and midbrain on T2-weighted images. (Figure) CT liver revealed cirrhosis, portal hypertension, and mild splenomegaly. Copper metabolism study confirmed low serum copper (8 µmol/L) and high 24-hr urine copper (234 µg/d) consistent with diagnosis of WD. He was promptly started on Zinc and Trientine 250 mg daily. After one month, the patient was re-admitted for worsening dysphagia, dysarthria and rigidity, eventually becoming bedridden with inability to talk and eat requiring G-tube placed). Liver biopsy showed cirrhosis with little inflammatory activity and abundant copper on Rhodanine stain ( >600 mcg/g). The patient underwent OLT after being granted a Metabolic MELD exception of 40 due to medically unresponsive neurological impairment, with preserved liver function (calculated MELD 8). Post-OLT, he had gradual neurological improvement, except persistent dystonia and spasticity. Serum ceruloplasmin levels normalized but repeat MRI showed persistent signal alterations at the basal ganglia and brainstem. At 16 month follow-up, his neurological recovery remained largely stagnant with minimal improvement in extrapyramidal symptoms. Discussion: OLT for management of neurological WD remains highly debatable. Most data on neurological recovery after LT are based on patients with mixed liver and neurological involvement with success rate of 62%. In our patient, he failed to display complete neurological recovery 1.5 years after OLT despite initial improvement. The rapid neurologic deterioration that led to OLT occurred after initiation of chelation therapy which may indicate paradoxical worsening. Additional research is needed to determine the timing of OLT and role of medical optimization prior to OLT in patients with neurological WD.Figure 1.: (A) MRI Brain with contrast showing (T2/FLAIR) hyperintensity and mild edema symmetrically in the caudate heads, putamina, ventral lateral thalami, and midbrain. Findings are suspicious for Wilson Disease. (B) Cirrhotic nodules accompanying mild chronic inflammation (Hematoxylin and eosin, 100X). (C) The liver cells of this cirrhotic nodule are extensively filled with copper (Rhodanine stain, 100X) (D) The liver cells show bright red granules of copper in the cytoplasm (Rhodanine stain, 200X).

6-Year-Old Male Drowning Complicated by Cardiac Arrest and Ensuing Metabolic and Respiratory Acidosis: Should Presence of Pulses Lead Clinicians to Pursue Prolonged Cardiopulmonary Resuscitation?

BackgroundDrowning is one of the leading causes of death in the pediatric population. Patients arriving to the emergency department (ED) with submersion injuries are often asymptomatic and well-appearing, but can sometimes present critically ill and require prolonged resuscitation. The question of how long to continue resuscitation of a pediatric patient with a submersion injury is a difficult question to answer. Case ReportWe present a case of 6-year-old boy was found by his friends submerged in sea water for 10–15 min. The patient was rescued by lifeguards and evaluated by emergency medical personnel, who found him breathing spontaneously but unresponsive. En route to hospital, the patient became apneic, cardiopulmonary resuscitation (CPR) was started, and the patient was intubated. The patient arrived to the ED in cardiopulmonary arrest, CPR was continued and epinephrine was administered. Return of spontaneous circulation was achieved after 42 min in the ED. Initial laboratory test results showed severe acidosis and chest x-ray study showed diffuse interstitial edema. Ventilator settings were adjusted in accordance with lung protective ventilation strategies and the acidosis began to improve. Over the next several days, the patient was weaned to noninvasive ventilation modalities and eventually made a complete neurologic recovery and continued to be a straight-A student.Why Should an Emergency Physician Be Aware of This?We make the case that, in select drowning patients, duration of CPR longer than 30 min can potentially result in favorable neurologic outcomes. Prolonged CPR should be especially strongly considered in patients with a pulse at any point during evaluation. With the combination of prolonged CPR and judicious use of lung protective mechanical ventilation strategies, we were able to successfully treat the patient in our case.

Retrospective analysis of deformed complex vertebral osteotomy in children with severe thoracic post-tubercular angular kyphosis

BackgroundMany surgical options have been described to manage post-tubercular kyphosis, but the standard approach for treating severe post-tubercular angular kyphosis in children has not been established yet. The present study was performed to evaluate the safety and efficacy of deformed complex vertebral osteotomy (DCVO) for the treatment of severe thoracic post-tubercular angular kyphosis (> 70°) in children.MethodsDeformed complex vertebrae indicated that multiple deformed and fused vertebrae were usually involved with two or more vertebral bodies and the partial or total fusion of many segments' facet joints and intervertebral discs. Thus, DCVO indicated that a wider posterior wedge-shaped and three-column osteotomy was performed within deformed complex vertebrae to correct a more extensive range of angles. From 2010 to 2017, 15 children who suffered from severe thoracic post-tubercular angular kyphosis underwent DCVO. Deformed complex vertebrae involved two vertebral bodies in 9 patients and three vertebral bodies in 6 patients. The Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) were assessed preoperatively and at the final follow up. This was a retrospective study analysing the outcome after grade 4/5 spinal osteotomies in deformed complex vertebrae.ResultsThe mean duration of surgery was 239 ± 37.81 min. The average period of follow-up was 31.6 ± 6.98 months. The preoperative mean kyphosis of deformed complex vertebrae was 83.39° ± 9.04°; the mean thoracic kyphosis (TK) and lumbar lordosis (LL) were 81.09° ± 8.51° and 80.51° ± 7.64°, respectively; the mean sagittal vertical axis (SVA) was 3.83 cm ± 1.43 cm. The postoperative mean kyphosis of deformed complex vertebrae was reduced to 19.98° ± 2.47° (P < 0.001) with a mean kyphosis correction of 63.41°; at the final follow up, it was 18.4° ± 2.29° (P < 0.001) without obvious loss of correction. The postoperative mean TK, LL, and SVA were reduced to 24.05° ± 3.84°, 46.9° ± 3.53°, and 0.6 cm ± 0.34 cm, respectively (P < 0.001 for all); and there was no obvious loss of sagittal alignment and balance at the final follow up (p = 0.982, p = 0.604, p = 0.754). Complicated with neural dysfunction preoperatively, 5 Frankel's grade D cases showed complete neurological recovery at final follow up. VAS score reduced from 3.6 ± 1.18 to 0.87 ± 0.64 (P < 0.001); and ODI score reduced from 22.21 ± 6.93 to 5.02 ± 2.6 (P < 0.001) at the final follow up.ConclusionsDCVO was an individualized osteotomy for treating severe thoracic post-tubercular angular kyphosis in children and could be safe and effective in reducing the incidence of complications and significantly improving kyphosis correction.

A-279 Progressive Neuropsychological Deficits Secondary to an Acute Disseminated Encephalomyelitis Attack 11 Years Later Complicated by Possible New Pathology

Abstract Objective: Acute Disseminated Encephalomyelitis (ADEM) often presents as an abrupt, brief, and intense attack causing widespread inflammation and demyelination to the central nervous system. Most patients typically make a complete neurological recovery; however, a few demonstrate long-term, persistent impairments. Method: A 64-year-old white female presented for a neuropsychological evaluation (2021) following a progressive one-year decline in her memory and motor abilities, which per family, reportedly overlay persisting residual deficits from an ADEM attack she had in 2010. Nearly 11 years following the attack, she reported continued reliance on her family in completing most of her instrumental, and even some basic activities of daily living since the attack. Initial neuroimaging following the attack (2010) revealed extensive bilateral white matter (WM) lesions, whereas current neuroimaging (2021) (despite not explicitly commenting on the resolution status of her lesions), continued to reveal widespread hyperintense signals in WM regions, progressing cerebral atrophy, and the possibility of superimposed normal pressure hydrocephalus (i.e., ventriculomegaly). Results: Her neuropsychological profile (with no prior baseline) was marked by substantial impairments in immediate and delayed verbal/visual memory, attention, language, motor abilities, visuospatial skills, executive functions, along with mild anxiety. Conclusions: This neurocognitive profile displayed atypical findings in patient recovery following an ADEM attack. Given the test results and the continued presence of extensive hyperintense signals in WM regions, it is possible her initial brain lesions (due to ADEM) remained unresolved. This, along with the possible intervening effects of new pathology (e.g., NPH and possible vascular changes) are likely exacerbating her existing deficits related to ADEM.

What Is Currently Known about Intramedullary Spinal Cord Abscess among Children? A Concise Review

Intramedullary spinal cord abscesses (ISCA) are rare. Typical symptoms include signs of infection and neurological deficits. Symptoms among (younger) children can be highly uncharacteristic. Therefore, prompt and proper diagnoses may be difficult. Typical therapeutic options include antibiotics and neurosurgical exploration and drainage. In this review, we analyze published cases of ISCA among children. Most pediatric cases were found to be under the age of 6 years. The typical symptoms included motor deficits in 89.06%, infection signs in 85.94%, and sensory deficits in 39.06%. Urinary dysfunction was observed in 43.75%, and bowel dysfunction in 17.19%. The predisposing factors included dermal sinuses, (epi)dermoid cysts, prior infection, iatrogenic disorder, and trauma. The most common pathogens were: Staphylococcus aureus, Mycobacterium tuberculosis, Escherichia coli, and Proteus mirabilis. The pediatric population has good outcomes as 45.93% of patients had complete neurological recovery and only 26.56% had residual neurological deficits. Fifteen (23.44%) had persistent neurological deficits. Only one (1.56%) patient died with an ISCA. In two (3.13%) cases, there were no details about follow-up examinations.

“Through and Through” Fluoroscopically Guided Catheter Drainage of Extensive Spinal Epidural Abscess: A Case Report

Purpose: We aimed to present a case of spondylodiscitis with extensive spinal epidural abscess (SEA) that was successfully treated using a minimally invasive technique supplemented with fluoroscopically guided catheter drainage and systemic antibiotic therapy. Methods: A 58-year-old man presented with severe back pain and high-grade fever. He had progressive radiating pain in the lower extremities, followed by sensory deficits in both the lower limbs. Laboratory investigations revealed leukocytosis and high C-reactive protein levels. Magnetic resonance imaging of the thoracic and lumbar regions revealed an extremely large posterior SEA that extends from T6 to S1. As the patient did not respond to intravenous antibiotics alone, he underwent skipped laminectomies with fluoroscopically guided catheter drainage and irrigation. Results: Escherichia coli were detected in purulent material from the abscess. His clinical symptoms were dramatically and immediately relieved after the procedure. The patient achieved complete neurological recovery after six weeks of antibiotic therapy. Conclusions: We suggest a limited approach to the spine with the use of small radio-opaque catheters, representing an interesting option to effectively drain extensive SEAs with less morbidity than the conventional open extensive surgical drainage.

O062 Acquired carotid-jugular fistulas following carotid endarterectomy: a narrative review

Abstract Introduction Acquired arterio-venous fistulas (AVF) involving the carotid artery are most commonly the result of trauma and catheterisation of the neck vessels. Left untreated, carotid-jugular fistulas (CJF) may precipitate ischaemic neurological symptoms due to thromboembolism or shunting of blood through the AVF. Methods A literature review was performed to determine the incidence and outcomes of acquired carotid-jugular AVFs following carotid endarterectomy (CEA). Electronic searches were performed using three databases, PubMed, EMBASE, and Google Scholar. Results Three case studies met inclusion criteria for analysis. The first case occurred 4-months following a left CEA. CT-angiography and duplex ultrasound identified a pseudoaneurysm arising from the proximal internal carotid artery. A CJF was identified on re-intervention and carotid ligation was performed following unsuccessful attempts to repair the defect. The patient has ongoing mild dysphonia with no other complications at 18 months follow-up. The second case occurred 6 years following right CEA. Catheter angiography revealed an AVF between the right external carotid artery (ECA) and internal jugular vein, treated with coil embolization. The patient made complete neurological recovery and had no further complications at 2 years follow-up. The third case occurred 4 years following right CEA. Catheter angiography identified fistulisation between the lingual branch of the right ECA and right retromandibular vein, treated with transarterial particle embolization. The patient made a complete neurological recovery. Conclusion Carotid-jugular AVFs are rare following CEA. This review proposes that carotid-jugular AVFs may be amenable to both open and endovascular intervention with durable outcomes. Proceduralists should be cognisant of this complication. Take-home message Carotid-jugular arteriovenous fistulas are rare following carotid endarterectomy and may be amenable to both open and endovascular intervention with durable outcomes.

Case report: a special case of cryptococcal infection-related inflammatory syndrome in a non-HIV infected and non-transplant patient

BackgroundCryptococcal meningoencephalitis (CM) is a severe infection of central nervous system with high mortality and morbidity. Infection-related inflammatory syndrome is a rare complication of CM. Herein, we report a case of CM complicated by infection-related inflammatory syndrome.Case presentationA 42-year-old man with chronic hepatitis B presented with a 3-day history of aphasia and left hemiparesis at an outside medical facility. The brain magnetic resonance imaging (MRI) showed symmetric and confluent hyperintense signal abnormalities mainly located in the basal ganglia, internal capsule, external capsule, periventricular, corona radiata, frontal and temporal lobes. Cerebrospinal fluid (CSF) examinations revealed elevated leukocyte and protein. India ink staining was positive for Cryptococcus. CSF culture and metagenomic next-generation sequencing (mNGS) confirmed Cryptococcus neoformans. Initial response was observed with intravenous fluconazole (400 mg per day). However, 11 days later, he developed impaired consciousness and incontinence of urine and feces. A repeat brain MRI showed the lesions were progressive and enlarged. The patient was referred to our department at this point of time. Repeat CSF analysis (India ink staining, culture and mNGS) re-confirmed Cryptococcus. However, clinical worsening after initial improvement, laboratory examinations and brain MRI findings suggested a diagnosis of infection-related inflammatory syndrome. Therefore, a combination of corticosteroids and antifungal therapy was initiated. At follow-up, a complete neurological recovery without any relapse was documented. The repeat brain MRI showed complete resolution of the previous lesions.ConclusionsThis case demonstrated that cryptococcal inflammatory syndromes must be suspected in cases of CM if an otherwise unexplained clinical deterioration is observed after initial recovery. The same can happen even before the primary infection is controlled. Thus, timely identification and prompt treatment is vital to reduce the mortality and disability of CM. The administration of corticosteroids in combination with antifungal therapy is an effective strategy in such cases.Graphical abstractClinical course and treatment process of the patient. Hemiparalysis and aphasia improved after the initiation of antifungal treatment. However, the patient developed impaired consciousness companied by deterioration of brain MRI findings. He was treated with adjunctive glucocorticoid taper therapy consisting of dexamethasone (20 mg/day, intravenously) for 1 week followed by oral prednisone 1 mg/kg/day, tapered based on clinical and radiological response, along with amphotericin B (0.6 mg/kg/day, intravenously), voriconazole (400 mg/day in 2 divided doses, intravenously), and 5-flucytosine (100 mg/kg/day in 4 divided doses, orally). Two weeks later, his symptoms improved significantly. After discharge, he began oral voriconazole for consolidation and maintenance therapy for 8 weeks and 9 months respectively. He recovered without any neurological sequelae at 6-month follow-up. Note: MRI = magnetic resonance imaging.

Central Pontine Myelinolysis Complicating Hodgkin Lymphoma: A Case Report &amp; Review of Literature

Central Pontine myelinolysis is a demyelinating disorder generally caused by rapid correction of hyponatremia and is a debilitating condition. Here we describe an interesting case of a 38 year old man diagnosed with Hodgkin lymphoma who developed CPM prior to start of the first cycle of chemotherapy with no antecedent hyponatremia and had complete neurological recovery.

Spontaneous Spinal Epidural Haematoma Mimicking a Heart Attack: A Case Report

Introduction: Spontaneous spinal epidural hematoma (SSEH) is a rare disease. Typical symptoms develop chest and back pain, numbness, radicular paresthesis, sensory deprivation and progressive paralysis. SSEH sometimes mimics other diseases like stroke, lung pathologies, myocard infarctus (MI). This situation makes it difficult to treat this pathology. Case Report: We presented a case with epidural hematoma which compressing the spinal cord at the T2-4 level. He had applied to our emergency service with acute severe chest pain and numbness. He was given clopydogrel, acetylsalicylic acid for the medical treatment of MI by the cardiologist. Therefore, progressive paralysis of lower limbs, incontinence and sensory deprivation were developed. Laminectomy and hematoma evacuation were performed. After phisical therapy, he had a complete neurological recovery on the postoperative day 14.&#x0D; Coclusion: SSEH should be kept in mind and early surgical treatment should be performed if neurological deterioration develops.

Lichtheim disease: A rare manifestation of pernicious anemia

Subacute combined degeneration of the spinal cord (SACD) is an important neurological complication of vitamin B12 deficiency. It is an important treatable cause of progressive neurological disability. We report a case of a 12-year-old girl, which presented with features of SACD of the spinal cord with low vitamin B12 levels and positive anti-parietal cell antibodies, suggesting vitamin B12 deficiency due to autoimmune etiology. The girl was started on a regimen of intramuscular vitamin B12 treatment. After which she had complete neurological recovery. She was advised of lifelong supplementation of parenteral vitamin B12 due to the autoimmune etiology.

A novel strategy sequentially linking mechanical cardiopulmonary resuscitation with extracorporeal cardiopulmonary resuscitation optimizes prognosis of refractory cardiac arrest: an illustrative case series

BackgroundExtracorporeal membrane oxygenation (ECMO) to support cardiopulmonary resuscitation (CPR), also known as extracorporeal cardiopulmonary resuscitation (ECPR), has shown encouraging results in refractory cardiac arrest (RCA) resuscitation. However, its therapeutic benefits are linked to instant and uninterrupted chest compression (CC), besides early implementation. Mechanical CC can overcome the shortcomings of conventional manual CC, including fatigue and labor consumption, and ensure adequate blood perfusion. A strategy sequentially linking mechanical CPR with ECPR may earn extra favorable outcomes.Case seriesWe present a four-case series with ages ranging from 8 to 94 years who presented with prolonged absences of return of spontaneous circulation (ROSC) after CA associated with acute fulminant myocarditis (AFM) and myocardial infarction (MI). All the cases received VA-ECMO (ROTAFLOW, Maquet) assisted ECPR, with intra-aortic balloon pump (IABP) or continuous renal replacement treatment (CRRT) appended if persistently low mean blood pressure (MAP) or ischemic kidney injury occurred. All patients have successfully weaned off ECMO and the assistant life support devices with complete neurological recovery. Three patients were discharged, except the 94-year-old patient who died of irreversible sepsis 20 days after ECMO weaning-off. These encouraging results will hopefully lead to more consideration of this lifesaving therapy model that sequentially integrates mechanical CPR with ECPR to rescue RCA related to reversible cardiac causes.ConclusionsThis successful case series should lead to more consideration of an integrated lifesaving strategy sequentially linking mechanical cardiopulmonary resuscitation with ECPR, as an extra favorable prognosis of refractory cardiac arrest related to this approach can be achieved.

Pediatric stiff limb syndrome with polyautoimmunity of anti-GAD-65, anti-islet cell, and thyroid peroxidase antibodies: A case report and review of literature

We report an early childhood onset Stiff Limb Syndrome (SLS) in association with unusual polyautoimmunity of GAD-65, anti-islet cell, and Thyroid Peroxidase (TPO) autoantibodies, who has achieved a nearly complete neurological recovery following combined immunotherapy, symptomatic and physical therapy. The patient had normal MRIs of the brain and spinal cord and a negative paraneoplastic work-up. Subsequently, she developed hypothyroidism requiring levothyroxine supplementation. We then conducted an extensive review of literature and identified 52 previously reported pediatric Stiff Man Syndrome (SMS)/Stiff Person Syndrome (SPS) or SLS cases, which has demonstrated a common association with other systemic autoimmune conditions. In the available literature, screening for concurrent autoimmunity has only been reported infrequently. We found that a paraneoplastic process is extremely rare in pediatric cases. Timely diagnosis and initiation of immunotherapy are critical to a favorable outcome. Therefore, we recommend to include SMS/SPS or SLS as an important differential diagnosis for MRI-negative myelopathy. Further clinical and research efforts should be focused on understanding the role of both genetic predisposition and environmental insults in the autoimmunity of pediatric SMS/SPS or SLS.

Severe Carbamazepine Toxicity Treated with Continuous Venovenous Hemofiltration at Palestine Medical Complex: Two Case Reports

Carbamazepine intoxication is not uncommon and accounts for many cases of poisoning among anticonvulsive medications users. Since there is no specific antidote for carbamazepine overdose, management is limited to gastric decontamination and supportive therapy. With its high protein binding, the role of extracorporeal elimination in carbamazepine intoxication is still questionable. Here two cases of severe carbamazepine intoxication are presented; the cases were brought to the emergency department after the ingestion of 12,000 mg of controlled release carbamazepine for the first case, and unknown amounts of the same drug for the second case. Both cases were presented with altered mental status, convulsion, and high serum carbamazepine levels of more than 20 mcg/mL. They were intubated and treated with continuous venovenous hemofiltration, after which carbamazepine levels declined significantly along with subsequent clinical improvement and complete neurological recovery. Both cases were discharged home for further psychiatric care.

De Novo Glioblastoma Masqueraded within a Hemispheric Dural Meningiomatosis: Rare Imaging Findings and Rationale for Two-Staged Resection

Introduction Collision tumors present as histologically different juxtaposed neoplasms within the same anatomical region, independent of the adjacent cell population. De novo intracranial collision tumors involving metachronous primary brain neoplasms alongside dural meningiomatosis are not well documented in the literature. Clinical Presentation We present staged surgical management of a 72-year-old female with known left hemispheric stable dural-based convexity mass lesions over 10 years and new-onset expressive aphasia and headaches. MRI had revealed left supratentorial dural-based enhanced masses consistent with en plaque meningiomatosis. Embolization angiography showed an unusual tumor blush from an aberrant branch of anterior cerebral artery suggesting a deeper focal intra-axial nature; a stage 1 craniotomy for dural-based tumor resection was completed with diagnosis of a meningioma (WHO grade 1). Intraoperatively, a distinct intra-axial deep discrete lesion was verified stereotactically, concordant with the location of tumor blush. The patient made a complete neurological recovery from a transient postoperative supplemental motor area syndrome in a week. Subsequent postoperative follow-up showed worsening of right hemiparesis and MRI showed an increase in residual lesion size and perilesional edema, which prompted a stage 2 radical resection of a glioblastoma, WHO grade 4. She improved neurologically after surgery with steroids and physical therapy. At 15 months following adjuvant therapy, she remains neurologically intact throughout the postoperative course, with no recurrent tumor on MRI. Conclusion A de novo glioblastoma presented as a masquerading lesion within hemispheric convexity meningiomatosis in an elderly patient with no prior radiation/phakomatosis, inciting a non-causal juxtapositional coexistence. The authors highlight rare pathognomonic angiographic findings and the rationale for two-staged resections of these collision lesions that led to excellent clinicoradiological outcome.

Spontaneous acute spinal subdural hematoma in patient on oral anticoagulant therapy

Introduction: Spontaneous spinal subdural hematoma as a result of coagulation deficit is a very rare and serious condition, with an overall incidence of less than 1%. Symptoms can vary according to the level of the bleed. Prompt recognition of the presence of spinal subdural hematoma is crucial for treatment. MRI is the investigation of choice for diagnosis as well as for planning the surgery. The differential diagnosis includes abscess, lipomatosis, significant discal hernia and tumours. There are no definite guidelines for the management of spinal subdural hematomas. In cases with serious neurological deficits, prompt surgical evacuation may lead to the resolution of symptoms and complete neurological recovery.&#x0D; Case report: We present a case of a 75-years-old man with bilateral lower limb radiculopathy, paresthesias, and spinal claudications for four days, progressing to bilateral paraplegia with urine incontinency. The patient was diagnosed with cauda equina syndrome due to spontaneous spinal subdural hematoma in the region from Th12 to L2. He was immediately operated and the subdural hematoma was evacuated. Minimal recovery was achieved and the patient was referred for further rehabilitation with severe paraparesis and urine incontinence.&#x0D; Conclusion: Early diagnosis of spinal subdural hematoma is essential for treatment. Any delay of correct diagnosis can lead to a devastating neurological deficit. Spontaneous spinal subdural hematoma is one of the rare conditions where an emergency MRI is indicated and crucial for diagnosis.

Acute onset common peroneal nerve palsy in a child due to fibular head osteochondroma: a case report

&lt;p class="abstract"&gt;A 7-year-old patient presented with acute onset spontaneous common peroneal nerve (CPN) palsy due to osteochondroma of fibular head. Osteochondroma was excised resulting in complete neurological recovery. As per our knowledge, this is the first case of an acute onset CPN palsy in a child due to osteochondroma. 14 studies reporting patients with CPN palsy due to osteochondroma were analyzed. Of 24 patients reported with this condition in literature, 19 (79%) recovered completely from CPN palsy. Incomplete recovery after surgery was associated with a longer mean duration between symptoms and surgery (26 months versus 5 months for complete recovery). &lt;/p&gt;

Electroactive Scaffolds to Improve Neural Stem Cell Therapy for Spinal Cord Injury.

Spinal cord injury (SCI) is a serious condition caused by damage to the spinal cord through trauma or disease, often with permanent debilitating effects. Globally, the prevalence of SCI is estimated between 40 to 80 cases per million people per year. Patients with SCI can experience devastating health and socioeconomic consequences from paralysis, which is a loss of motor, sensory and autonomic nerve function below the level of the injury that often accompanies SCI. SCI carries a high mortality and increased risk of premature death due to secondary complications. The health, social and economic consequences of SCI are significant, and therefore elucidation of the complex molecular processes that occur in SCI and development of novel effective treatments is critical. Despite advances in medicine for the SCI patient such as surgery and anaesthesiology, imaging, rehabilitation and drug discovery, there have been no definitive findings toward complete functional neurologic recovery. However, the advent of neural stem cell therapy and the engineering of functionalized biomaterials to facilitate cell transplantation and promote regeneration of damaged spinal cord tissue presents a potential avenue to advance SCI research. This review will explore this emerging field and identify new lines of research.