Decline In Neurological Status Research Articles

Reporting on Neurological Decline as Identified by Hourly Neuroassessments.

BACKGROUND: Hourly neurological examinations (neuro exam) have been widely used to monitor for a decline in neurological status, allowing for timely intervention. There are, however, limited data behind this common practice. The objective of this study was to identify how frequently neurological decline occurred across various diagnoses and whether that decline (1) was identified by a scheduled neurocheck and (2) altered management. METHODS: A cross-sectional survey was performed in a neurological intensive care unit at a tertiary care academic medical center. Clinical neuroscience nurses caring for patients with hourly neurological assessments completed a brief survey at 12-hour shift completion. RESULTS: Data were collected from 212 nurse's shifts. Neurological changes were identified by nurses in 14% (n = 30) of shifts. The neurological change was identified during a scheduled neurocheck 67% of the time, with the detection of changes more likely to occur during a scheduled neuro exam than at other times ( P < .05). There was no change to the care plan in 55% of the cases of neurological decline. Patients with subarachnoid hemorrhage were more likely to have a decline detected. CONCLUSION: Findings suggest that many patients undergo hourly neurological exams without ever identifying a neurological deterioration. In many instances of neurodeterioration, there was no change to the treatment plan pursued. Primary diagnoses and neurological changes may not be entirely independent, and therefore, hourly neuro exams may have greater yield in some diagnoses than others. Replication is warranted with a larger sample to evaluate the risks and benefits of neuroassessments.

Intravenous thrombolysis for mild stroke: NIHSS 3–5 Versus NIHSS 0–2

Background and purposeStudies have shown that mild stroke patients with National Institutes of Health Stroke Scale (NIHSS) score 3–5 but not 0–2 may benefit from the intravenous thrombolysis when compared with antiplatelet therapy. We aimed to compare the safety and effectiveness of thrombolysis in mild stroke with NIHSS score of 0–2 vs. 3–5 and identify the predictors of an excellent functional outcome in a real world longitudinal registry. MethodsIn a prospective thrombolysis registry, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had initial NIHSS scores ≤ 5. Demographic data, medical history, pre–stroke medications, imaging data, and laboratory measures were collected. The outcome of interest was modified Rankin Scale score of 0 to 1 at discharge. Safety outcome was evaluated by syptomatic intracrerebral hemorrhage defined as any decline in neurologic status due to hemorrhage within 36 h. Multivariable regression models were performed to explore the safety and effectiveness in the alteplase–treated patients with admission NIHSS 0–2 vs. 3–5 and identify factors independently associated with an excellent functional outcome. ResultsOf a total of 236 eligible patients, those with an admission NIHSS score of 0–2 (n=80) had a better functional outcome at discharge compared with NIHSS 3–5 group (n=156) (81.3% vs. 48.7%, adjusted odds ratio [aOR] 0.40, 95% confidential interval [CI] 0.17 – 0.94, P=0.04) without increasing the rate of symptomatic intracerebral hemorrhage and mortality. Non–disabling stroke (Model 1: aOR 0.06, 95%CI 0.01–0.50, P=0.01; Model 2: aOR 0.06, 95% CI 0.01–0.48, P=0.01) and prior statin therapy (Model 1: aOR 3.46, 95% CI 1.02–11.70, P=0.046; Model 2: aOR 3.30, 95% CI 0.96–11.30, P=0.06) were independent predictors of excellent outcomes. ConclusionsAcute ischemic stroke patients with admission NIHSS 0–2 was associated with better functional outcomes at discharge compared with NIHSS 3–5 within the 4.5–hour time window. Minor stroke severity, non–disabling stroke and prior statin therapy were independent predictors for funcitonal outcomes at discharge. Further studies with large sample size are needed to confirm the findings.

Brain Alterations in Aged OVT73 Sheep Model of Huntington's Disease: An MRI Based Approach.

Huntington's disease (HD) is a fatal neurodegenerative autosomal dominant disorder with prevalence of 1 : 20000 that has no effective treatment to date. Translatability of candidate therapeutics could be enhanced by additional testing in large animal models because of similarities in brain anatomy, size, and immunophysiology. These features enable realistic pre-clinical studies of biodistribution, efficacy, and toxicity. Here we non-invasively characterized alterations in brain white matter microstructure, neurochemistry, neurological status, and mutant Huntingtin protein (mHTT) levels in cerebrospinal fluid (CSF) of aged OVT73 HD sheep. Similar to HD patients, CSF mHTT differentiates HD from normal sheep. Our results are indicative of a decline in neurological status, and alterations in brain white matter diffusion and spectroscopy metric that are more severe in aged female HD sheep. Longitudinal analysis of aged female HD sheep suggests that the decline is detectable over the course of a year. In line with reports of HD human studies, white matter alterations in corpus callosum correlates with a decline in gait of HD sheep. Moreover, alterations in the occipital cortex white matter correlates with a decline in clinical rating score. In addition, the marker of energy metabolism in striatum of aged HD sheep, shows a correlation with decline of clinical rating score and eye coordination. This data suggests that OVT73 HD sheep can serve as a pre-manifest large animal model of HD providing a platform for pre-clinical testing of HD therapeutics and non-invasive tracking of the efficacy of the therapy.

Ultra‐Early Functional Improvement After Stroke Thrombectomy – Predictors and Implications

Background Neurocritical care is routinely provided to patients post‐endovascular thrombectomy (EVT) for anterior large vessel occlusion strokes. We aim to study the relationship between immediate improvement in National Institutes of Health Stroke Scale (NIHSS) score on outcomes post‐EVT and potential implications for postprocedural care. Methods We performed a retrospective review of anterior circulation large vessel occlusion (internal carotid/proximal middle cerebral artery) patients undergoing EVT. Demographic, clinical, and imaging information was analyzed. Ultra‐early functional improvement (UEFI) was defined as NIHSS score &lt;6 within 30 minutes of successful recanalization. We analyzed the incidence and predictors of UEFI, and explored reasons for neurological decline post‐UEFI. Results Of the 343 anterior large vessel occlusion patients undergoing EVT, mean age was 71 ± 15 and 46% were male. Mean NIHSS was 17 ± 6 and Time Last Known Well (TLKW) to arrival was 9 ± 11 hours. UEFI was observed in 23% (79/343) of patients. Independent predictors of UEFI included lower pretreatment NIHSS, favorable Alberta Stroke Program Early CT Score (ASPECTS), and lower admission systolic blood pressure. Rates of 90‐day‐modified Rankin scale 0–2 were higher (71% versus 33%, P &lt;0.01) and the rate of mortality (8% versus 28%, P &lt;0.01) was lower in the UEFI group compared with the non‐UEFI group. Amongst patients with UEFI, 1.3% (1/79) experienced increase in NIHSS by ≥4 points within 24 hours of EVT. This patient received thrombolysis, achieved TICI‐2B recanalization, and follow‐up neuroimaging revealed a parenchymal hemorrhage and an infarct volume of 44 mL. None of the patients with UEFI required continuous antihypertensive infusions. Conclusions Approximately 1‐in‐4 of anterior large vessel occlusion stroke patients undergoing EVT have an NIHSS score of &lt;6 within 30 minutes of successful recanalization. Only 1% of them experience significant decline in neurological status within 24 hours of the procedure with the majority achieving functional independence at 90 days. The need for advanced neurocritical care should be reevaluated in these patients.

Abstract 1122‐000215: Scheduled Head CT in Neurologically Stable Spontaneous ICH Patients May be Unnecessary

Introduction : Obtaining serial head computed tomography (CTH) imaging for patients with spontaneous intracerebral hemorrhage (sICH) is commonly utilized to monitor for hematoma expansion (HE), defined as an increase in ICH volume by 33%. Obtaining recurrent CTH in the ICU setting may burden nursing and transport staff, expose patients to radiation, and inflate healthcare costs. It remains unclear whether utilizing scheduled CTH for sICH patients is more advantageous than targeted CTH, which is prompted by a decline in neurological status. We reviewed clinical factors and imaging studies in patients with and without HE. Methods : This retrospective cohort study conducted over two years identified 171 sICH patients. Patient demographics, clinical and neuroimaging data were recorded (including the reason for repeat imaging). These variables were then compared and analyzed in relation to HE using SPSS version 26, chi‐square tests for categorical variables, and independent‐samples t‐tests were used for continuous variables. Results : Patients were predominantly male (65%), with a mean age of 65±14 years, a median GCS of 14, a median ICH score of 1, and a median ICH volume of 12.1 ccs. Repeat CTH was obtained within 14 hours after the initial imaging on average. Admission blood pressure (BP), BP‐lowering interventions, pre‐admission use of anticoagulant and antiplatelet therapy, GCS on admission, ICH volume, ICH score, and presence of spot signs were similar between the two groups. 15% of total patients (26/171) had HE. In the group that underwent scheduled repeat CTH, only 7% (9 patients) had HE, while the remaining 93% (119 patients) did not. Patients who underwent a second scan following a change in the neurologic assessment included 39% (17 patients) who had HE, compared to 61% (26 patients) that did not. HE detection was significantly lower in patients that underwent scheduled CTH (p &lt; 0.0001). Conclusions : In patients with a stable exam, scheduled head CT only showed HE in 6% of patients; thus, the excess burden, radiation, and costs may not be necessary for these patients. Hematoma expansion is significantly lower in patients who underwent scheduled imaging than those prompted by a decline in neurologic status. However, our sample size is small and additional studies with larger population sizes are required to validate our findings.

A CASE OF DISSEMINATED NOCARDIA INFECTION IN AN ADULT WITH PANCYTOPENIA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Nocardia is an infrequent cause of bacterial infection caused by weakly acid-fast actinomycete Nocardia. It causes opportunistic infections in immunocompromised hosts, including those with lymphomas, malignancies, HIV and those receiving steroids. Here, we present a case of Nocardia lung abscess that progressed to brain abscesses in an immunocompromised state. CASE PRESENTATION: 65-year-old male with history of CKD from glomerulonephritis/p-ANCA vasculitis presented with pancytopenia. He worked as a pipe fitter with significant exposure to soil. He had been treated with prednisone and cyclophosphamide for 7 months, and then switched to azathioprine. There was concern of thrombotic microangiopathy given elevated LDH and presence of schistocytes on peripheral blood smear, however, ADAMST13 level was normal. He received plasma exchanges and started on eculizumab for treatment of presumptive atypical Hemolytic Uremic Syndrome (HUS). Clinical status deteriorated, and he developed worsening anemia, thrombocytopenia and renal function requiring hemodialysis. Thrombocytopenia and renal function failed to improve with eculizumab, and his vasculitis was thought to be the culprit. He was then found to have a pleural effusion, which was drained and revealed exudative fluid with cytology showing acute inflammatory cells. CT chest showed left lower lobe consolidation, left upper lobe airspace opacity and scattered pulmonary nodules. He received supportive blood and platelet transfusions. 25 days later, cultures from pleural fluid grew Nocardia. He had progressive decline in neurological status, and MRI revealed innumerable small enhancing lesions throughout brain and brainstem, likely from Nocardia. Subsequently, he developed seizures and intraparenchymal bleed due to the low platelets. Family eventually opted for comfort care measures only. DISCUSSION: Radiographic findings for Nocardia can be variable, including multifocal disease, nodules, infiltrates or cavitary lesions. Differentiating Nocardia from other filamentous fungi or mycobacteria can be challenging based on radiological finding alone. Pleural effusions can also occur in 10-33% of cases. Dissemination from the lungs can present as bacteremia, empyema, pericarditis, or can involve the CNS. CNS involvement of nocardia most commonly presents as brain abscesses. It has a high morbidity, and the mortality rate can be close to 30% versus 10% for other bacterial abscesses. CONCLUSIONS: We report how an immunocompromised state due to medications can be a reason for the development of Nocardia lung abscess. Failure of early detection and aggressive treatment can result in dissemination of the bacteria. Nocardia may have an indolent presentation and detection may be challenging, but with the risk factors and soil exposure taken into account, it should be considered a differential to help avoid significant morbidity and mortality. Reference #1: Beaman B.L., Burnside J., Edwards B., Causey W. Nocardial infections in the United States, 1972-1974. J Infect Dis. (1976);134(3):286–289 Reference #2: Saubolle, Michael A., and Den Sussland. “Nocardiosis: Review of Clinical and Laboratory Experience.” Journal of Clinical Microbiology 41.10 (2003): 4497–4501 Reference #3: Mamelak AN, Obana WG, Flaherty JF, Rosenblum ML. Nocardial brain abscess: Treatment strategies and factors influencing outcome. Neurosurgery. 1994;35:622-31 DISCLOSURES: No relevant relationships by Aqsa Amin, source=Web Response No relevant relationships by Ming-Yan Chow, source=Web Response

P31. Intraoperative complications and neurologic changes following posterior thoracic corpectomies via a costotransversectomy type approach

BACKGROUND CONTEXT Iatrogenic cord injuries, dural tears, and pleural injuries are operative risks associated with thoracic corpectomies via costotransversectomy approaches (TCCA). Few studies have comprehensively described the rates of intra-operative complications including motor score changes, intraoperative neuromonitoring changes, dural tears, and pleural injuries. PURPOSE We seek to describe the rates and sequelae of changes to lower extremity motor score (LEMS), neuromonitoring signal changes, dural tears and pleural injuries in patients undergoing TCCA. STUDY DESIGN/SETTING Retrospective chart review conducted at a single academic referral center. PATIENT SAMPLE A total of 118 consecutive patients undergoing TCCA over a 10-year period with documented preoperative and post-operative motor examinations. OUTCOME MEASURES Outcomes included documented LEMS (out of 50) and intraoperative neuromonitoring changes. Pleural and dural injuries and subsequent treatment were assessed. METHODS Data were retrospectively collected from operative notes, intraoperative neuromonitoring reports, and the post-operative inpatient and outpatient clinical notes. Preoperative LEMS greater than or equal to 48 were considered intact. Post-operative LEMS were categorized into improved, unchanged or lower as compared to the preoperative scores. Categorical data was assessed with the Fisher's Exact test. Significance was set at p=0.05. RESULTS Lower extremity motor scores: Of the 118 patients, 68 were intact pre-operatively and 50 were not intact. Four percent of non-intact patients demonstrated a declining post-operative examination as compared to 14.7% of intact patients (p CONCLUSIONS Most patients undergoing TCCA procedures have unchanged or improved LEMS by discharge. Approximately 10% of patients had an initial decline in their LEMS with less than 3% of patients demonstrating lasting decline in neurologic status at final follow-up. Most neuromonitoring changes occurred at the time of corpectomy or graft/cage placement. Intraoperative pleural and dural injures during these procedures generally only require simple routine treatment. This information can be valuable in counseling patients regarding the risk of neurologic outcome, dural tear, and pleural injury following TCCA. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

THER-05. SOLITARY CEREBRAL METASTASIS FROM TRANSITIONAL CELL CARCINOMA OF THE BLADDER

INTRODUCTION: Brain metastasis is the most common neurological neoplasia seen in adults. They typically metastasize from primary lung or breast but very seldom is bladder cancer the culprit. Transitional cell carcinoma (TCC) of the bladder accounts for less than 1% of brain metastasis and few cases have been reported in literature. Here we present a rare case of TCC presenting with signs of neurological impairment. CASE DESCRIPTION: A 75-year-old male with history of TCC presented to the emergency department with right upper extremity hemiparesis and dysarthria of 5 hours duration. He had undergone cystoscopy with resection of tumor 3 years prior followed by gemcitabine chemotherapy and combination radiotherapy/immunotherapy. CT imaging revealed a hyperdense 3.3 cm mass in the left frontoparietal region with internal hemorrhage measuring 1.4 cm and surrounding vasogenic edema. He was immediately treated with high dose corticosteroids and antiepileptics which did not result in improvement of his symptoms. Metastatic workup which included contrast enhanced CT of chest, abdomen and pelvis revealed no evidence of local or metastatic recurrence. Due to rapid worsening of his status, respiratory failure and encephalopathy, family did not want to pursue additional treatment and decided on inpatient hospice. The patient died 3 weeks later due to rapid neurological decline. DISCUSSION: According to literature, CNS involvement of disseminated TCC varies from 0.6% - 8%, and bladder carcinoma accounts for 0.5% of all intracranial metastases. Incidence of CNS involvement without evidence of recurrence or disseminated disease is extremely uncommon. Aggressive multitherapeutic regimens, which include gemcitabine, have been favored for its penetration of the blood-brain barrier but even with its use disease may present years later with an unfavorable prognosis. Although metastasis from TCC of the bladder is rare any decline in neurological status should warrant further investigation in these patients.

Rehabilitation of multiple sclerosis patients in India.

Multiple sclerosis (MS) is a chronic progressive disease which is one of the leading causes of handicap in young subjects. The large range of symptoms associated with MS lead to continuing decline in neurologic status and quality of life. The coexistence of physical and cognitive impairments, together with the imprevisible evolution of the disease makes MS rehabilitation very challenging. The main objective of rehabilitation is, therefore, to ease the burden of symptoms by improving self-performance and independence. Inpatient, outpatient and Home rehabilitation with multidisciplinary team has been shown to be beneficial in improving disability. Individualized programs elaborated by a multidisciplinary team of experts are the key to success of rehabilitation. Family plays a big role and Family Based Rehabilitation will be important in long term rehab program in MS.

A short-chain alkyl derivative of Rhodamine 19 acts as a mild uncoupler of mitochondria and a neuroprotector

Limited uncoupling of oxidative phosphorylation is known to be beneficial in various laboratory models of diseases. The search for cationic uncouplers is promising as their protonophorous effect is self-limiting because these uncouplers lower membrane potential which is the driving force for their accumulation in mitochondria. In this work, the penetrating cation Rhodamine 19 butyl ester (C4R1) was found to decrease membrane potential and to stimulate respiration of mitochondria, appearing to be a stronger uncoupler than its more hydrophobic analog Rhodamine 19 dodecyl ester (C12R1). Surprisingly, C12R1 increased H+ conductance of artificial bilayer lipid membranes or induced mitochondria swelling in potassium acetate with valinomycin at concentrations lower than C4R1. This paradox might be explained by involvement of mitochondrial proteins in the uncoupling action of C4R1. In experiments with HeLa cells, C4R1 rapidly and selectively accumulated in mitochondria and stimulated oligomycin-sensitive respiration as a mild uncoupler. C4R1 was effective in preventing oxidative stress induced by brain ischemia and reperfusion in rats: it suppressed stroke-induced brain swelling and prevented the decline in neurological status more effectively than C12R1. Thus, C4R1 seems to be a promising example of a mild uncoupler efficient in treatment of brain pathologies related to oxidative stress.

Abstract W P64: DRAGON Score Outperforms 7 Other Hemorrhagic Transformation Scores in Ischemic Stroke Patients Treated With IV r-tPA

Introduction: Hemorrhagic transformation (HT) is a major complication of IV r-tPA therapy following ischemic stroke. At least 8 scores have been proposed to predict HT in patients undergoing IV thrombolytic therapy; however, studies comparing these 8 scores in an independent dataset are missing. Hypothesis: We tested the hypothesis that stroke metrics can predict adverse outcome after r-tPA therapy. Methods: Clinical data was analyzed from consecutive patients (n = 187) receiving IV r-tPA therapy from January 2009 until May 2013 at the Yale New Haven Stroke Center. 8 stroke metrics were calculated for each patient: DRAGON, ASTRAL, Stroke-TPI, HAT score, MSS, SITS-ICH, SEDAN and SPAN-100. Adverse outcome was assessed by presence of symptomatic intracerebral hemorrhage (sICH). The NINDS trial defined a hemorrhage as symptomatic if it was not seen on a previous CT scan and there had subsequently been either a suspicion of hemorrhage or any decline in neurologic status. Univariate logistic regression was performed using each stroke metric as an independent variable and sICH as the dependent variable. Receiver Operating Characteristic (ROC) analysis was used to test goodness of fit by the DeLong method. Results: 18 patients (9.6%) had a symptomatic intracerebral hemorrhage after IV rt-PA treatment. Only 4 scores showed good agreement with sICH (ROC area &gt; 0.7): DRAGON (0.76 ± 0.12), ASTRAL (0.73 ± 0.11), Stroke-TPI (0.72 ± 0.11) and HAT score (0.71 ± 0.13) with odds ratios as follows: DRAGON (1.73 ± 0.47), ASTRAL (1.10 ±0.06), Stroke-TPI (1.04 ± 0.03) and HAT score (2.0 ± 0.67). Conclusions: The DRAGON score yielded the highest combination of ROC area and odds ratios, and thus performed best at predicting sICH in our independent dataset. While the HAT score yielded a higher odds ratio, it yielded a lower ROC area and was therefore less robust at predicting sICH. Our results demonstrate the potential utility of the DRAGON score as a predictor of adverse clinical outcome in patients undergoing IV r-tPA. Further studies are warranted to assess its discriminatory ability in a large prospective cohort.

Abstract W P265: Improved Symptomatic ICH Rates for Ischemic Stroke Patients Receiving IV rtPA

Introduction: Symptomatic intracranial hemorrhage (sICH) is a concerning complication after the administration of IV r-tPA for treatment of acute ischemic stroke. Results from the NINDS trial demonstrated a 6.2% sICH rate. As such, acute stroke teams have used this data as a benchmark to compare their program’s complication rate related to IV r-tPA treatment in acute ischemic stroke. Hypothesis: We examined the percent of acute ischemic stroke patients treated with IV r-tPA each year who developed sICH, and compared our sICH rate with the NINDS benchmark data for this adverse outcome. We anticipated that the sICH rate would decline with additional experience and expanded use of evaluation and treatment protocols at our institution. Methods: Clinical data was analyzed from consecutive patients (n = 187) receiving IV rt-PA therapy from January 2009 until December 2012 at the Yale-New Haven Hospital. Adverse outcome was assessed by presence of symptomatic intracerebral hemorrhage (sICH). According to the NINDS definition, a hemorrhage was considered symptomatic if it was not seen on a previous CT scan and there had subsequently been either a suspicion of hemorrhage or any decline in neurologic status. The proportion of patients with sICH was calculated for each year and pairwise comparisons were made using two-sample tests of proportions. Results: 18 out of 187 patients (9.6%) who received IV r-tPA therapy between 2009 and 2012 developed sICH after IV r-tPA treatment. When analyzed by year, 17.74% of sICH cases occurred in 2009, and this proportion decreased to 11.76% in 2010 (p-value = 0.4424), to 8.89% in 2011 (p-value = 0.1952) and to 2.86% in 2012 (p-value = 0.0329). Conclusions: The proportion of ischemic stroke patients who were treated with IV rt-PA and subsequently developed sICH decreased each year from 2009 to 2012 at our center. This difference reached statistical significance by 2012. Our program’s expanded experience and focused approach using current guidelines and latest published practices likely explain the two-fold reduction in complication rates when compared to the NINDS benchmark. Further studies are warranted to compare our clinical decision-making protocol to proposed models for predicting adverse outcome after IV rt-PA therapy.

Stroke: Highlights of Selected Articles

<i>Stroke:</i> Highlights of Selected Articles

Short-term Outcomes of US Air Force Critical Care Air Transport Team (CCATT) Patients Evacuated from a Combat Setting

Purpose. The purpose of this study is to describe the short-term outcomes (during air transport) of patients managed by the United States Air Force Critical Care Air Transport Teams (CCATT). Methods. This is a retrospective chart review of patients who were transported by CCATT between March 1, 2007 and June 30, 2008. A standardized abstraction form was used. Patients were classified as medical or trauma. Care given inflight was documented, including mechanical ventilation, vasoactive medication administration, and administration of blood products. Short-term events (during air transport) included death, oxyhemoglobin desaturation, hypotension, decline in neurological status, development of anuria or oliguria, and dislodgement of endotracheal and chest tubes. Results. A total of 656 patient moves met inclusion criteria, of which 425 (64.8%) were trauma and 231 (35.2%) were medical. Mechanical ventilation was required by 318 (49%), 68 (10%) received vasoactive medications, and 43 (7%) required blood products during the flight. There were a total of 75 events documented on 65 patient transports (10%). Of these, 19 were oxyhemoglobin desaturation, 29 were hypotension, 3 were decline in neurological status, and 23 were due to anuria or oliguria. We did not encounter any deaths or loss of airway or chest tubes during transport. Conclusion. CCATTs are a successful platform in transporting critically injured/ill patients with minimal short-term complications. Key Words: Critical Care Air Transport; emergency medical services; prehospital; resuscitation; tactical combat casualty care

MRI Findings in a Dog with Kernicterus

A severe increase in total bilirubin coincided with a decline in neurologic status to comatose in a 9 yr old spayed female mixed-breed dog being treated for immune-mediated hemolytic anemia. MRI of the brain was performed to investigate potential causes for the neurologic signs. MRI revealed bilaterally symmetrical hyperintensities within the caudate nuclei, globus pallidus, thalamus, deep cerebellar nuclei, and cortical gray matter on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences, which coincided with areas of bilirubin deposition and neuronal necrosis (kernicterus) identified on necropsy examination. This is the second case report of an adult dog exhibiting kernicterus, and the first report to document MRI findings associated with that condition. Kernicterus is an uncommonly reported complication of hyperbilirubinemia in dogs, but is potentially underreported due to difficulties in recognizing subtle lesions and distinguishing kernicterus from other potential causes of neurologic abnormalities with readily available antemortem tests. MRI may be helpful in supporting the diagnosis of kernicterus.

Pedicle screw fixation for traumatic fractures of the thoracic and lumbar spine

Spine fractures are common. The treatment of traumatic fractures of the thoracic and lumbar spine remains controversial but surgery involving pedicle screw fixation has become a popular option. To assess the effects (benefits and harms) of pedicle screw fixation for traumatic fractures of the thoracic and lumbar spine. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, 2011 Issue 1), MEDLINE (1948 to March 2011), EMBASE (1980 to 2011 Week 11), the Chinese Biomedical Database (CBM Database) (1978 to March 2011), the WHO International Clinical Trials Registry Platform (March 2011), reference lists of articles and conference proceedings. Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing pedicle screw fixation and other methods of surgical treatment, or different methods of pedicle screw fixation, for treating traumatic fractures of the thoracic and lumbar spine. Three review authors independently performed study selection, risk of bias assessment and data extraction. Limited meta-analysis was performed. Pedicle screw fixation versus other methods of surgery that do not involve pedicle screw fixation was not looked at in any of the identified trials. Studies that were identified investigated different methods of pedicle fixation.Five randomised and three quasi-randomised controlled trials were included. All were at high or unclear risk of various biases, including selection, performance and detection bias. A total of 448 patients with thoracic and lumbar spine fractures were included in the review. Participants were restricted to individuals without neurological impairment in five trials. The mean ages of study populations of the eight trials ranged from 33 to 41 years, and participants had generally experienced traumatic injury. Mean follow-up for trial participants in the eight trials ranged from 28 to 72 months.Five comparisons were tested.Two trials compared short-segment instrumentation versus long-segment instrumentation. These studies found no significant differences between the two groups in self-reported function and quality of life at final follow-up. Aside from one participant, who sustained partial neurological deterioration that was resolved by further surgery (group not known), no neurological deterioration was noted in these trials.One trial comparing short-segment instrumentation with transpedicular bone grafting versus short-segment fixation alone found no significant difference between the two groups related to patient-perceived function and pain at final follow-up. All participants had normal findings on neurological examination at final follow-up.Two trials compared posterior instrumentation with fracture level screw incorporation ('including' group) versus posterior instrumentation alone ('bridging' group). Investigators reported no differences between the two groups in patient-reported function, quality of life, or pain at final follow-up. One trial confirmed that all participants had normal findings on neurological examination at final follow-up.One trial comparing monosegmental pedicle screw instrumentation versus short-segment pedicle instrumentation found no significant differences between the two groups in Oswestry Disability Index results or in pain scores at final follow-up. No neurological deterioration was reported.Three trials compared posterior instrumentation with fusion versus posterior instrumentation without fusion. Researchers found no differences between the two groups in function and quality of life or pain. No participants showed a decline in neurological status in any of the three trials, and no significant difference was reported between groups in the numbers whose status had improved at final follow-up. Two trials stated that patients in the fusion group frequently had donor site pain. Other reported complications included deep vein thrombosis and superficial infection. This review included only eight small trials and five different comparisons of methods of pedicle fixation in various participants while looking at a variety of outcomes at different time points. Overall, evidence is insufficient to inform the selection of different methods of pedicle screw fixation or the combined use of fusion. However, in the absence of robust evidence to support fusion, it is important to factor the risk of long-term donor site pain related to bone harvesting into the decision of whether to use this intervention. Further research involving high-quality randomised trials is needed.

Neurosurgical complications of left ventricular assist devices in children

Left ventricular assist devices (LVADs) are continuous or pulsatile flow devices that could potentially be life-saving measures for patients with end-stage heart failure. These devices have clear advantages over extracorporeal membrane oxygenation (ECMO) and are often used in adults. They are only recently being commonly used in the pediatric age group. As the use of LVADs becomes more mainstream in children, it is important to determine the complication profile associated with these devices. Furthermore, with the increasing application of LVADs in children, pediatric neurosurgeons are seeing a correlative increase in associated neurological complications. In this study, the authors reviewed the incidence of neurological complications due to LVAD use in the pediatric age group and the role of neurosurgery in treatment. The authors examined data regarding patients with LVADs from the Texas Children's Hospital Heart Center database (July 01, 2007, to June 30, 2011) and recorded neurological complications requiring neurosurgical consultation. They identified 2 children who underwent craniotomies during LVAD treatment. Intracranial hemorrhage occurred in 3 (6.5%) of the 46 patients treated with an LVAD at the authors' institution. Of these patients, 2 were treated with craniotomies for life-threatening intracranial hemorrhages. The 3 patients in the neurosurgical cohort presented with cerebral infarction, decreased level of consciousness, and/or seizure. At the last follow-up (286, 503, and 550 days), 1 patient (case 2) had no decline in neurological status, underwent a successful heart transplant, and was discharged home; 1 patient (case 1) died of refractory cardiac failure; and 1 patient (case 3) was on an LVAD for destination therapy (that is, the LVAD is not a bridge to transplantation but rather the final treatment). This patient was discharged from the hospital, but he died of overwhelming fungemia at 286 days while on VAD support. Intracranial hemorrhage is a serious and feared complication of LVAD treatment. While the surgical risk is substantial due to systemic anticoagulation and significant medical comorbidities, neurosurgical evacuation of hemorrhage plays an important life-saving role that can yield successful and acceptable outcomes.

Favourable outcome of progressive multifocal leukoencephalopathy with mefloquine treatment in combination with antiretroviral therapy in an HIV-infected patient

A 33-year-old man who developed progressive multifocal leukoencephalopathy (PML) with HIV infection is reported. The patient exhibited rapid decline in neurological status after initiation of antiretroviral therapy (ART), which was attributed to the PML-immune re-constitution inflammatory syndrome. Following the administration of mefloquine in combination with ART, the patient's neurological status improved substantially. This case suggests that further investigation of the use of mefloquine might be warranted for treatment of PML in HIV-infected patients.

Chapter 7. Neuroimaging

Chapter 7. Neuroimaging

Natural History of Perihematomal Edema After Intracerebral Hemorrhage Measured by Serial Magnetic Resonance Imaging

knowledge on the natural history and clinical impact of perihematomal edema (PHE) associated with intracerebral hemorrhage is limited. We aimed to define the time course, predictors, and clinical significance of PHE measured by serial magnetic resonance imaging. patients with primary supratentorial intracerebral hemorrhage ≥ 5 cm(3) underwent serial MRIs at prespecified intervals during the first month. Hematoma (H(v)) and PHE (E(v)) volumes were measured on fluid-attenuated inversion recovery images. Relative PHE was defined as E(v)/H(v). Neurologic assessments were performed at admission and with each MRI. Barthel Index, modified Rankin scale, and extended Glasgow Outcome scale scores were assigned at 3 months. twenty-seven patients with 88 MRIs were prospectively included. Median H(v) and E(v) on the first MRI were 39 and 46 cm(3), respectively. Median peak absolute E(v) was 88 cm(3). Larger hematomas produced a larger absolute E(v) (r(2)=0.6) and a smaller relative PHE (r(2)=0.7). Edema volume growth was fastest in the first 2 days but continued until 12 ± 3 days. In multivariate analysis, a higher admission hematocrit was associated with a greater delay in peak PHE (P=0.06). Higher admission partial thromboplastin time was associated with higher peak rPHE (P=0.02). Edema volume growth was correlated with a decline in neurologic status at 48 hours (81 vs 43 cm(3), P=0.03) but not with 3-month functional outcome. PHE volume measured by MRI increases most rapidly in the first 2 days after symptom onset and peaks toward the end of the second week. The timing and magnitude of PHE volume are associated with hematologic factors. Its clinical significance deserves further study.