Early Neurological Complications Research Articles

Emergency Surgical Management of Meningiomas: Factors Affecting Early Outcomes and Complications

Abstract Objective Intracranial meningiomas constitute a third of all brain tumors and are among the most common indications for neurosurgical procedures performed worldwide. Most meningiomas present with an indolent, longstanding history. However, the data on outcomes of emergency surgeries for meningioma is limited. This study aims to present our experience of urgent surgical intervention in patients with meningiomas presenting acutely. We also analyze the factors influencing early neurological outcomes and complications. Materials and Methods All nonelective meningioma surgeries done on an emergency basis between January 2015 and December 2019 were retrospectively reviewed. Patients' demography, clinical, and radiological details were recorded for analysis. The surgical procedure, complications, and follow-up outcomes were also included for statistical comparison. Results Forty-four patients qualified for the study with a mean age of 49.4 ± 13.4 years. The average presenting Glasgow Coma Scale (GCS) was 13; 47.7% of cases presented with altered sensorium. The most common lesion location was convexity (25, 56.8%), and the mean tumor volume was 74.1 ± 36.5 mL. Gross peritumor edema with mass effect was seen in 16 patients (36.4%). The mean Karnofsky Performance Status at 3 months' follow-up was 89.3 ± 18.2. Patient age and tumor size did not affect outcomes. The presenting GCS of < 15 (odds ratio [OR] 8.8, confidence interval [CI] 0.95–80.72, p 0.03) and the occurrence of postoperative complications (OR 25.71, CI 2.65–249.2, p 0.001) were associated with unfavorable outcomes. Although not statistically significant, a poor tumor grade was also associated with worse clinical outcomes (p 0.20). Conclusion Emergency meningioma surgery has comparable outcomes and complication rates with routine elective procedures. Grade II/III meningiomas are more likely to present with acute neurological deterioration and carry a relatively worse prognosis. Poor presenting GCS and postoperative complications are the most critical factors associated with poor patient outcomes in our study.

Frequency, risk factors, and outcome of neonatal meningitis in sepsis.

To determine the frequency, associated risk factors, and outcome of meningitis in neonates presenting with sepsis at Aga khan Tertiary Care Hospital, Karachi. A descriptive cross-sectional study was conducted at pediatrics department of Aga Khan Tertiary University Hospital, Karachi, Pakistan from July 31, 2020, till January 30, 2021. Neonates of either gender admitted with neonatal sepsis were enrolled using non-probability consecutive sampling technique. Meningitis was diagnosed as per the findings of cerebrospinal fluid (CSF) along with the outcome in terms of death and early neurological complications such as subdural effusions and hydrocephalus. Of 209 neonates with sepsis, meningitis was observed in 59 (28.2%) neonates. A significantly lower mean weight (p-value 0.024) while significantly higher mean duration of stay (p-value <0.001) was observed in patient with meningitis. Moreover, a significantly higher proportion of meningitis was observed in neonates who had fever (p-value 0.048), vomiting (p-value 0.009), abdominal distension (p-value <0.001), and blood culture positivity (p-value <0.001). Blood culture positive Methicillin-sensitive Staphylococcus aureus (MSSA) was considerably higher among neonates with meningitis. Of 59 neonates with meningitis, mortality was observed in 2 (3.4%) neonates. Positive CSF culture was observed in 6 (2.9%) while hydrocephalus was observed in 7 (11.9%) and effusion in 6 (10.2%) neonates. Neonatal meningitis is common in neonates presenting with sepsis, but mortality rate is low. Positive cultures, particularly with MSSA, further underscore the bacterial etiology in neonatal meningitis.

Extracorporeal Membrane Oxygenation after Pediatric Cardiac Surgery: A Single-Center Experience.

Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment option providing cardiopulmonary support when standard therapies prove insufficient for reversible diseases. The mean objective of this study was to evaluate our center's experience with ECMO following pediatric cardiac surgery. This retrospective study was conducted in our pediatric intensive care unit (PICU) between November 2014 and March 2021 and included patients who received ECMO following cardiac surgery. Over the 7-year period, 324 patients underwent cardiac surgery, of which 24 (7.4%) required ECMO support. Among them, 13 (54.2%) were female, with a median age of 16.0 (2.0- 208) months and a median weight of 7.0 (3.5-70) kg. The mean vasoactive inotrope score (VIS) was 53.9 ± 44.5. Atrioventricular septal defect repair was the most common surgical procedure (n = 8/24, 41.6%). The primary indication for ECMO was low cardiac output syndrome (LCOS) in 14 (58.3%) patients. The median duration of ECMO support was 6.0 (1.0-46.0) days. Nonsurvivors had significantly higher Pediatric Risk Score of Mortality (PRISM) III scores (P = .014) and VIS scores during the pre-ECMO period (P = .004). Early or late neurological complications developed in 12 (50%) patients, with significant differences in lactate levels and pH levels preECMO between those with and without neurological complications (P = .01, P = .02, respectively). We successfully decannulated 16 (66.6%) patients, with a final survival rate of 12 (50%). ECMO plays a crucial role in providing pre- and post-cardiac surgery support for children. LCOS remains the main indication, and high PRISM III and VIS scores are valuable predictors of outcomes.

Proximal sealing in the aortic arch for inner curve disease using the custom Relay scalloped and fenestrated stent graft

ObjectiveThis study aimed to analyze early and midterm results of custom-made proximal scallop and fenestrated stent grafts for thoracic endovascular aortic repair (TEVAR) with a proximal landing zone (PLZ) in the aortic arch. MethodsAll consecutive patients treated with the custom made proximal scalloped and fenestrated Relay stent grafts (Terumo Aortic Bolton Medical Inc.) in 10 Italian centers between January 2014 and December 2022 were included. The primary end points were technical success, incidence of intraoperative major adverse events, deployment accuracy, and rate of early neurological complications, endoleaks (ELs) and retrograde aortic dissection. ResultsDuring the study period, 49 patients received TEVAR with Relay custom-made endograft in Italy were enrolled. The median patient age was 70.1 years (interquartile range, 23-86 years) and 65.3% were male. The indication for treatment was atherosclerotic aneurysms in 59.2% of cases and penetrating aortic ulcer in 22.4%. The endograft configuration was proximal fenestration in 55.1% and scallop in 44.9%. The proximal landing zone was zone 0 in 25 cases (51%), zone 1 in 14 cases (28.6%), and zone 2 in 10 cases (20.4%). The supra-aortic debranching procedures were 38 (77.5%). Technical success was 97.9% (48/49) owing to one case (2.0%) of inaccurate deployment. Intraoperatively, one (2.0%) type Ia and one (2.0%) type III EL were detected. There were no cases of in-hospital mortality, major adverse events, or retrograde dissection. Three minor strokes (6.1%) (National Institutes of Health Stroke Scale score of ≤4) were observed. At a mean follow-up time of 36.3 ± 21.3 months the rate of types I to III ELs and reintervention was 4.1%, respectively. Four patients (8.2%) died during the follow-up period, one (2.1%) from abdominal aortic rupture and three (6.1%) from nonaortic causes. ConclusionsOur early and midterm outcomes suggest that scalloped and fenestrated TEVAR may provide an acceptable alternative treatment option for aortic arch pathologies. Large-scale studies are needed to assess the long-term durability of this technique.

Evaluation of risk factors for postoperative neurologic intensive care admission after brain tumor craniotomy: A single-center longitudinal study.

Perioperative variable parameters can be significant risk factors for postoperative intensive care unit (ICU) admission after elective craniotomy for intracranial neoplasm, as assessed by various scoring systems such as Cranio Score. This observational study evaluates the relationship between these factors and early postoperative neurological complications necessitating ICU admission. In total, 119 patients, aged 18 years and above, of either sex, American Society of Anesthesiologists (ASA) grades I-III, scheduled for elective craniotomy and tumor excision were included. The primary objective was to evaluate the relationship between perioperative risk factors and the incidence of early postoperative complications as a means of validation of the Cranio Score. The secondary outcomes studied were 30-day postoperative morbidity/mortality and the association with patient-related risk factors. Forty-five of 119 patients (37.82%) required postoperative ICU care with the mean duration of ICU stay being 1.92 ± 4.91 days. Tumor location (frontal/infratemporal region), preoperative deglutition disorder, Glasgow Coma Scale (GCS) less than 15, motor deficit, cerebellar deficit, midline shift >3 mm, mass effect, tumor size, use of blood products, lateral position, inotropic support, elevated systolic/mean arterial pressures, and duration of anesthesia/surgery were associated with a higher incidence of ICU care. Maximum (P = 0.035, AOR = 1.130) and minimum systolic arterial pressures (P = 0.022, Adjusted Odds Ratio (AOR) = 0.861) were the only independent risk factors. Cranio Score was found to be an accurate predictor of complications at a cut-off point of >10.52%. The preoperative motor deficit was the only independent risk factor associated with 30-day morbidity (AOR = 4.66). Perioperative hemodynamic effects are an independent predictor of postoperative ICU requirement. Further Cranio Score is shown to be a good scoring system for postoperative complications.

The lower Osteotomy Level is Associated With Decreased Revision Surgery Due to Mechanical Complications After Three-Column Osteotomy in Patients With Adult Spinal Deformity: A Multi-Institutional Retrospective Study.

A multi-institutional retrospective study. To investigate risk factors of mechanical failure in three-column osteotomy (3COs) in patients with adult spinal deformity (ASD), focusing on the osteotomy level. We retrospectively reviewed 111 patients with ASD who underwent 3COs with at least 2years of follow-up. Radiographic parameters, clinical data on early and late postoperative complications were collected. Surgical outcomes were compared between the low-level osteotomy group and the high-level osteotomy group: osteotomy level of L3 or lower group (LO group, n = 60) and osteotomy of L2 or higher group (HO group, n = 51). Of the 111 patients, 25 needed revision surgery for mechanical complication (mechanical failure). A lower t-score (odds ratio [OR] .39 P = .002) and being in the HO group (OR 4.54, P = .03) were independently associated with mechanical failure. In the analysis divided by the osteotomy level (LO and HO), no difference in early complications or neurological complications was found between the two groups. The rates of overall mechanical complications, rod failure, and mechanical failure were significantly higher in the HO group than in the LO group. After propensity score matching, mechanical complications and failures were still significantly more observed in the HO group than in the LO group (P = .01 and .029, respectively). A lower t-score and osteotomy of L2 or higher were associated with increased risks of mechanical failure. Lower osteotomy was associated with better correction of sagittal balance and a lower rate of mechanical complications.

Early neurologic complications after liver transplant are associated with reduced long-term survival and increased rates of rejection.

Neurologic complications (NCs) are common following liver transplantation (LT) and have been associated with impaired short-term survival. The impact of NC on long-term survival is less defined. We aimed to characterize these outcomes and assess for risk factors for post-LT NC. We performed a single-center, retrospective review of 521 patients with LT from 2016 to 2020. Baseline clinical and laboratory factors, intraoperative events, and outcomes were compared between patients with and without NC. The 5-year overall and rejection-free survival was estimated using the Kaplan-Meier analysis. Multivariable logistic regression assessed for an independent relationship between risk factors and the development of NC. Among 521 LT recipients, 24% experienced post-LT NC. Overall and rejection-free survival at 5 years was, respectively, 69% and 75% among those with NC versus 87% and 88% among those without NC (log-rank < 0.001). Among those who survived the first 3 months after LT, overall survival but not rejection-free survival was reduced among patients with NC. Risk factors for developing NC included peri-LT serum sodium (ΔSNa) ≥ 6 (29.4% vs. 20.5%, p = 0.04), grade 3 or 4 HE pre-LT, SNa < 125 pre-LT, and more intraoperative transfusions. In a multivariable logistic regression model controlling for described variables, SNa < 125 (or 0.21, 95% CI, 0.06-0.74) at LT and pre-LT HE grade 3 or 4 (or 0.45, 95% CI, 0.26-0.76) was independently associated with NC. Long-term survival was reduced among patients who developed NC in the immediate post-transplant period, even when censoring those who died in the first 3 months. Post-LT NC was associated with perioperative ΔSNa ≥ 6. Optimization of SNa pre-LT > 125 and limiting perioperative ΔSNa <6 mEq/L might have a beneficial impact in decreasing NC post-LT, which may improve long-term post-LT survival.

Incidence and Distribution of Various Arterial Territories Involved in Postoperative Neurological Complications in Patients Undergoing Cardiovascular Surgery: A Single Centre Retrospective Analysis

Background: Neurological complications (NCs) (stroke) remain a devastating complication after cardiovascular surgical procedures despite advances in perioperative monitoring and management. The incidence of NC related to cardiovascular surgeries (CS) is comparatively very high and associated with high morbidity and mortality. The aim of this study is to evaluate the overall incidence of neurological complications in adult as well as pediatric patients and various pattern of neurological injury on noncontrast computed tomography head (NCCT) associated with various types of CS. Materials and Methods: We retrospectively analyzed all the NCCT heads of the postoperative cardiovascular surgery patients done in the immediate and early postoperative period (&lt;7 days) who developed postoperative neurological deficits between April 2016 and February 2020. The medical records of all these cardiac surgery patients were analyzed for various variants such as the total number of patients who underwent CS, various types of cardiac surgery done during the study period, demographic information, associated comorbidities, various types of NC, postoperative data and various spectrum of computed tomography (CT) findings in the brain. Results: A total of 12,896 adult and pediatric cardiac surgeries were performed at our institute. Out of these, 1115 patients (8.6%) underwent CT brain for suspected neurological injury. A total of 215 patients (1.6%) had a positive finding on their NCCT head. Out of 215 patients, 148 (68.9%) were adult patients, whereas 67 (31.1%) were pediatric patients. A total of 156 (72.5%) patients had ischemic infarction (stroke), whereas hemorrhagic lesions were present in 59 patients (27.4%). The various types of positive CT scan findings were-156 ischemic infarcts (72.5%), 20 intraparenchymal hemorrhages (9.3%), 16 subdural hemorrhage (7.4%), 15 subarachnoid hemorrhage (6.9%), 01 cerebrovascular thrombosis (0.4%), and 07 intraventricular hemorrhage (3.2%). In an adult patient, pattern of ischemic infarct comprised middle cerebral artery (MCA) territory in 42 patients (41.5%), posterior territory in 34 patients (33.6%), anterior cerebral territory in seven patients (7.0%), multi-territory infracts in 11 patients (11.0%) and global ischemia in six patients (6.0%). Intraparenchymal hemorrhage was present in 17 patients (11.4%). In a pediatric subset of patient, the pattern of ischemic infarct included global hypoxic injury (GHI) in 30 patients (54.5%), posterior cerebral artery territory in nine patients (16.3%), MCA territory in eight patients (14.5%), multi-territory involvement in five patients (9.0%), and anterior cerebral artery territory in three patients (5.4%). In the hemorrhage group, five patients (7.4%) developed subarachnoid hemorrhage (SAH). Conclusion: In an adult patient, subset MCA territory infarcts were common in the infract group, whereas intra parenchymal haemorrhage (IPH) in the hemorrhage group. In the pediatric patient subset, GHI was common in infract group and SAH in hemorrhage group. Moreover, NCCT of the head is very useful in diagnosing early postoperative neurological complications in cardiovascular surgeries and managing the complications accordingly.

Risk Factors for Early Neurological Complications after Coronary Artery Bypass Graft versus Valve Replacement Surgery: Regional Cardiac Center Study

Risk Factors for Early Neurological Complications after Coronary Artery Bypass Graft versus Valve Replacement Surgery: Regional Cardiac Center Study

Early and long-term neurological complications of chemotherapy in oncology (literature review)

An analysis of the clinical manifestations of complications caused by the toxic effect of chemotherapeutic drugs used in the treatment of malignant neoplasms was carried out. The variety of clinical symptoms that develop against the background of chemotherapy for malignant neoplasms leads to difficulties in differential diagnosis of a primary neurological disease and the identification of complications during treatment. The severity of these complications depends on a number of factors, including the drug used, its dosage and duration of use, the use of various methods of combination therapy and radiation methods, as well as the presence of comorbid pathology in patients. A clear understanding of the mechanisms of development of neurotoxicity and timely diagnosis of such conditions is a priority task of modern clinical medicine Modern methods of treating patients with malignant neoplasms should be based on a multidisciplinary medical approach, including a set of measures to prevent unwanted toxic effects of treatment, stratify individual mortality risks and develop methods of rehabilitation and medical examination.

Neurological consequences of COVID-19.

In December 2019, cases of pneumonia caused by infection with the previously unknown severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), leading to coronavirus disease 2019 (COVID-19), were identified. Typical manifestations of COVID-19 are fever, cough, fatigue and dyspnoea. Initially, it was thought that the mechanism of action of SARS-CoV-2 was only associated with respiratory tract invasion, but it was later revealed that the infection might involve many other organs and systems, including the central and peripheral nervous systems. Neurological complications associated with SARS-CoV-2 infection include encephalopathy, encephalitis, meningitis, acute disseminated encephalomyelitis (ADEM), ischaemic and haemorrhagic stroke and cerebral venous sinus thrombosis. In cases of peripheral nervous system involvement, smell and taste disorders, myopathy or the signs and symptoms of Guillain‒Barré syndrome are observed. The most common early neurological complications, particularly during the first year of the epidemic, were anosmia and taste disorders, which, according to some studies, occurred in over 80 percent of patients with COVID-19. The proportion of patients with serious neurological manifestations was small compared to the global number of patients, but the numbers of SARS-CoV-2 infections and critical patients increased substantially. The experience from 2 years of the pandemic has shown that approximately 13% of infected patients suffer from severe neurological complications. The relationship between SARS-CoV-2 and the nervous system is not only a cause of neurological complications in previously healthy individuals but also directly and indirectly affects the courses of many nervous system diseases.

Prognostic significance of the clinical and radiological haemorrhagic transformation subtypes in acute ischaemic stroke: A systematic review and meta-analysis.

The aim was to investigate the associations of haemorrhagic transformation (HT) and its clinical and radiological subtypes with functional outcome, mortality, early neurological deterioration (END) and neurological complications in patients with acute ischaemic stroke (AIS). A systematic review and meta-analysis of observational studies on the associations of overall HT, clinical HT subtypes (asymptomatic intracerebral haemorrhage [aICH] and symptomatic intracerebral haemorrhage [sICH]) or radiological HT subtypes (haemorrhagic infarction [HI-1 or HI-2] and parenchymal haemorrhage [PH-1 or PH-2]) with prognosis in patients with AIS was performed. PubMed, Web of Science and Embase were systematically searched. Random effects models were used to calculate pooled estimates. Fifty-one studies with 100,510 patients were pooled in the meta-analysis. Overall HT was associated with worse functional outcome (odds ratio [OR] 2.12, 95% confidence interval [CI] 1.55-2.90), increased mortality (OR 1.87, 95% CI 1.52-2.30), END (OR 2.35, 95% CI 1.46-3.77), early-onset seizures (OR 2.58, 95% CI 1.63-4.10) and post-stroke epilepsy (OR 2.23, 95% CI 1.11-4.49). For clinical subtypes, sICH remained significantly associated with the aforementioned poor prognoses except post-stroke epilepsy, and aICH was associated with worse functional outcome but was unrelated to mortality. For radiological subtypes, PH (especially PH-2) was strongly associated with poor prognosis. HI-2 was associated with worse functional outcome, and HI-1 was associated with a lower risk of mortality and END. Regardless of whether AIS patients undergo thrombolysis or thrombectomy, overall HT, sICH and PH (especially PH-2) are associated with a substantially increased risk of worse functional outcome, mortality, END or neurological complications. The presence of aICH is related to worse functional outcome but is independent of increased mortality. HI-2 impairs functional independence, and HI-1 does not cause neurological impairment.

The incidence of early neurological complications after on-pump cardiac surgery: a retrospective study

Background: Cardiac surgery with cardiopulmonary bypass (CPB) is associated with a significant risk for neurological complications. Reported incidence and risk factors for these complications vary significantly. Identifying risk factors could lead to preventive strategies to reduce complications and improve patient’s outcome. Objective: The study aims to assess the overall incidence and risk factors for severe early postoperative neurological complications after elective on-pump cardiac surgery. We specifically analyzed the incidence of stroke, global cerebral ischemia (GCI) and epilepsy in these patients. Methods: After getting approval from the Ethics Committee Research UZ/KU Leuven, on 14/12/2021 (s65871), we retrospectively evaluated data of 1080 adult patients after cardiac surgery with CPB between 06/2019 and 06/2021 at the University Hospitals Leuven. After exclusion of emergency procedures and patients who died before neurological evaluation, 977 patients remained for primary analysis. All data were collected from the electronic patient’s file. Primary objective was to identify the incidence of stroke, GCI and epilepsy. We defined stroke and GCI according to the American Stroke Association. Secondary endpoints were identifying independent risk-factors and assessing the impact of early neurological complications on mortality. Statistical analysis was performed using econometric and statistical modeling with python. We performed univariate logistic regression with Bonferonni correction and multivariable logistic regression with backwards elimination approach and p-value set to be &lt;0.05. Results: The overall incidence of defined neurological complications after elective on-pump cardiac surgery at our institution was 3.17% (n=31) (stroke 2.35% (n=23), epilepsy 0.61% (n=6) and GCI 0.31% (n=3)). No statistically significant risk factors for these complications were found. In secondary analysis, patients with stroke and GCI had a higher risk of in-hospital mortality (Fisher’s exact test resulted in odds ratio 7.23 with p=0.005 and odds ratio 65.17 with p=0.003 respectively) Diabetes mellitus, preoperative atrial fibrillation, and endocarditis were also significantly related to in-hospital mortality. Conclusions: The incidence of early neurological complications after elective on-pump cardiac surgery at our institution was comparable to that reported in earlier studies. No independent risk factors for these neurological complications were found. The occurrence of stroke and GCI significantly increased in-hospital mortality which emphasizes the importance of these complications, with possible mortality benefit of early recognition and management of stroke.

Neurological complications in adult allogeneic hematopoietic stem cell transplant patients: Incidence, characteristics and long-term follow-up in a multicenter series.

Neurological complications (NCs) represent a diagnostic and clinical challenge in allogeneic hematopoietic stem cell transplant (alloHSCT) patients. We retrospectively analyzed NC incidence, etiology, timing, characteristics, outcome, and long-term effects in 2384 adult patients transplanted in seven Italian institutions between January 2007 and December 2019. Ninety-three (3.9%) patients were affected by 96 NCs that were infectious (29.2%), immune/inflammatory (26%), drug-related (12.5%), cerebrovascular (5.2%), metabolic (3.1%), related to central nervous system disease relapse (11.5%) and malignancy (3.1%), or undefined (9.4%). Six patients (6.4%) had neurological manifestations of chronic graft-versus-host disease (GVHD). NCs occurred on average at day +128 (from -5 to +4063). Early (< day +120) and late NCs had similar frequencies (46.9% vs 53.1%, p = 0.39). Thirty-one patients (33.3%) were affected by acute or chronic GVHD at the NC onset. With a median follow-up of 25.4 (0.4-163) months, the overall mortality due to NCs was 22.6%. The median time between NC onset and death was 36 (1-269) days. Infectious NCs were the main cause (61.9%) of NC-related mortality. A persistent neurological impairment occurred in 20.4% patients, 57.9% of whom being affected by immune/inflammatory NCs. This study highlights the rare, yet severe impact of alloHSCT-associated NCs on patient survival and long-term functional ability.

Tacrolimus-Induced Neurotoxicity in Early Post-Liver Transplant Saudi Patients: Incidence and Risk Factors.

BackgroundTacrolimus is a calcineurin inhibitor (CNI) commonly used as an immunosuppressant to prevent the rejection of organ transplants. After liver transplantation, it can cause early neurological complications, known as early calcineurin inhibitor-induced neurotoxicity (ECIIN). Its management requires CNI withdrawal, a measure that can affect post-transplant outcomes, primarily allograft rejection. In addition, it can negatively impact the quality of life. The incidence and risk factor of ECIIN has not been reported in the Saudi population. We investigated the incidence and risk factors of ECIIN after liver transplant in Saudi patients. We also looked at the length of stay in the Intensive Care Unit, hospital, and 30-day mortality as secondary endpoints.Material/MethodsThis was a retrospective cohort study of adult patients on tacrolimus with mild, moderate, or severe neurological events within the first month after liver transplantation at a single center of patients who meet the inclusion criteria and were over age 14 years. A total of 338 patients were included in the analysis, and the sample size was calculated based on a pilot study.ResultsAmong 338 liver transplantation patients, 63 patients (19%) developed ECIIN. Forty-eight percent of patients had seizures, 23% had agitation, 21% had psychosis, 10% had severe tremors, 13% had confusion, and 6% developed coma. The median time of the incident to develop ECIIN was 9 (IQR: 5–13.5) days after transplant. Thirty-eight patients were managed by switching to cyclosporine, 12 required a reduction in the dose, and 3 were managed temporarily by discontinuing therapy. Autoimmune hepatitis as an underlying liver disease was one of the statistically significant risk factors (P=0.0311). The median length of hospital stay was 31 (IQR: 21–75.5) days, ICU length of stay was 10 (IQR: 5–20.5) days, and 8 patients died within 30 days after transplant.ConclusionsThe incidence of ECIIN in Saud Arabia was similar to that reported in other populations with similar risk factors. Electrolyte imbalance, mainly hyponatremia, was significantly associated with developing ECIIN. Therefore, ECIIN may potentially increase hospital and ICU length of stay.

The relation between neurological outcomes and in-hospital mortality rates of endovascular aortic repair patients

Aim&#x0D; To represent our results of EVAR/TEVAR procedures for thoracoabdominal aortic pathologies and the relation between the post-procedural neurological adverse events and in-hospital mortality. &#x0D; Material and Method&#x0D; Patients who underwent EVAR/TEVAR procedures between November 2016 and May 2021 included in this retrospective study. Patients with a history of any cerebrovascular event before the intervention were excluded. Patients divided into two groups according to occurrence of any early neurological complications.&#x0D; Results&#x0D; A total of 60 patients who underwent EVAR/TEVAR procedures were evaluated. Group 1 included 37 (78.7%) patients who had no neurological complication. Group 2 included 10 (21.3%) patients who had a postoperative neurological complication. The intensive care unit stay time was significantly longer in Group 2 than Group 1 (1.7 ± 2.0 days in Group 1 vs 6.2 ± 5.1 days in Group 2, p=0.021). Overall mortality rate was 19.1% (9 of 47 patients). The mortality rate of the Group 2 was significantly higher than Group 1 (2 of 37 (5.4%) patients in Group 1 vs 7 of 10 patients (70%) in Group 2, p=0.001). American Society of Anesthesiologists physical classification score was significantly higher in Group 2 than Group 1 (3.5 ± 0.6 in Group 1 vs 4.1 ± 0.3 in Group 2, p=0.016). The most common early postoperative neurological complication was lack of recovery of consciousness (no postoperative consciousness).&#x0D; Conclusion&#x0D; The occurrence of any postoperative neurological adverse event has an additive effect to the in-hospital mortality rate of TEVAR and EVAR procedures.

Early Neurologic Complications and Long-term Neurologic Outcomes of Extracorporeal Membrane Oxygenation Performed in Children.

We aimed at evaluating acute neurologic complications (ANC) and clinical outcome at a 2-year follow-up in children after extracorporeal membrane oxygenation (ECMO). We conducted a single-center, retrospective review of our patient cohort aged between 1 month and 18 years at the time of ECMO support (between June 2014 to January 2017). Outcome analysis included ANC and their clinical consequences.The Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) were used for neurologic assessment performed at discharge from the hospital and at 2nd year follow-up. There were 35 children who required ECMO. The median ECMO time was 9 days (range 2-32 days). Decannulation from ECMO was achieved in 68.6% of patients, and overall, 42.8% survived (15 patients), The incidence of ANC in the surviving patients was 40% (6 children). ANC were intracranial hemorrhage, seizures, cerebral infarction, which occurred in one, two and three of the 15 surviving patients respectively (6.6, 13.3 and 20%). A higher rate of organ failure was related to death (p=0.043), whereas duration on ECMO was a risk factor for the development of ANC (p<0.05). At hospital discharge, the 14 patients evaluated had normal development or -mild disability in 73.2%, and at the 2-year follow-up, 93.4% had these scores. Children who receive ECMO have a risk to develop ANC, which was related to the length of ECMO treatment, while survival was related to less organ failure, Long-term neurological outcome was good in our patient cohort.

Modified transventricular and transaortic mitral valve edge-to-edge repair mimicking MitraClip overcorrection.

ObjectiveIn the current study, we present our mid-term experience with modified edge-to-edge repair technique through a transventricular and transaortic route in patients requiring left ventricular remodeling or aortic root/valve surgery.MethodsFrom December 2006 through April 2015, 49 high-risk patients (median age: 69 years; median European System for Cardiac Operative Risk Evaluation II: 11.4 [6.54-14.9]) underwent transventricular (N = 7; 14%) or transaortic (N = 42; 86%) edge-to-edge mitral valve repair. The Alfieri stitch technique was modified by MitraClip type overcorrection and solid buttressing behind the posterior leaflet. Indication was grade 2+ functional mitral valve incompetence and dilated or impaired left ventricle (N = 25; 52%), or grade 3+ (N = 22; 45%) and grade 4+ functional mitral valve regurgitation (N = 2; 4%). Surgical procedure included aortic root surgery in 65%, aortic valve replacement with surgical revascularization in 18%, and Dor-plasty with surgical revascularization in 14%.ResultsIntraoperative mortality and early neurologic complications were absent in our series. Ninety-day mortality was 12.2% (N = 6). Median clinical and echocardiographic follow-up-time was 50.7 (21.5-44.1) and 39.2 (33.7-44.1) months, respectively. Median postoperative transvalvular gradient was low (2.72 [1.91-4.22] mm Hg) and did not increase during follow-up (P = .268), although peak gradient rose slightly from 7.41 to 8.12 mm Hg (P = .071). The actuarial reoperation free rate at the index valve was 96.8%.ConclusionsTransventricular or transaortic Alfieri mitral repair mimicking mitral clip overcorrection represents a quick and safe technique in the setting of high-risk patients undergoing left ventricular remodeling or aortic root/valve surgery and can be performed with low risk of creating mitral stenosis at midterm. The technique is straightforward, with reliable identification of the center of the valve leaflets being the limitation.

Neurological aspects of COVID-19

The coronavirus disease COVID-19 began to spread worldwide in December 2019 from the city of Wuhan (China). COVID-19 is often accompanied by fever, hypoxemic respiratory failure and systemic complications (for example, gastrointestinal, renal, cardiac, neurological, and hepatic lesions), thrombotic phenomena. Central nervous system damage is caused by the primary effect on it, direct neuroinvasion of the virus, and more often by secondary effect due to systemic hyperinflammation. Neurological manifestations include fatigue, headache, insomnia, and olfactory/taste disorders. Neurological manifestations and complications of COVID-19 are diverse: (1) cerebral circulatory disorders, including ischemic stroke and macro/microhemorrhages; (2) encephalopathy; (3) para/postinfectious autoimmune complications, such as GuillainBarre syndrome; (4) meningoencephalitis; (5) neuropsychiatric complications (psychosis and mood disorders). In terms of pathogenesis, neurological disorders in COVID-19 can be caused by neurotropicity and neurovirulence of SARS-CoV-2, cytokine storm, hypoxemia, homeostasis disorders, as well as their combined effects. COVID-19 adversely affects the course and prognosis of chronic neurological disorders in comorbid patients. The review highlights the need for vigilance to early neurological complications in patients infected with SARS-CoV-2 and other coronaviruses, especially since some neurological complications may precede respiratory manifestations.

Retrospective Analysis of Clinical and Radiologic Data Regarding Zygomatic Implant Rehabilitation with a Long-Term Follow-Up.

Background: Zygomatic implants have been introduced to rehabilitate edentulous patients with severely atrophic maxillae. Their use has been reported by several studies, describing high overall survival rates at medium–long follow-up. The aim of this study was to retrospectively analyze if a few patient-related and implant-related features are correlated with implant success or the onset of complications. Materials and methods: Data of patients treated with zygomatic implants between May 2005 and November 2012 at three private clinics were collected and retrospectively analyzed. For each implant, the following data were collected: implant length, insertion path, ridge atrophy and sinus characteristics (width, pneumatization, thickness of mucosae, patency of sinus ostium). General patient characteristics and health status data were also recorded. The outcomes evaluated were implant failure, infective complications, early neurologic complications and overall complications. Results: A total of 33 patients (14 men, 17 women, mean age 59.1) that received 67 zygomatic implants were included in the study. The mean duration of the follow-up was of 141.6 months (min 109; max 198). In this period, a total of 16 (23.88%) implants in 8 (24.24%) patients were removed and 17 (51.51%) patients with 36 (53.73%) implants reported complications. Immediate loading resulted in a significantly lower risk of complications compared with the two-stage prosthetic rehabilitation (OR: 0.04, p = 0.002). A thickness of the sinus mucosa > 3 mm emerged to be correlated with a greater occurrence of infective complications (OR: 3.39, p = 0.019). Severe and extreme pneumatization of the sinus was significantly correlated with the incidence of overall complications (p = 0.037) and implant failure (p = 0.044). A large sinus width was predisposed to a higher risk of neurologic complications, infective complications and implant failure (p = 0.036, p = 0.032, p = 0.04, respectively). Conclusions: zygomatic implants are an alternative procedure for atrophic ridge rehabilitation when a conventional implant placement is not possible. Several clinical and anatomical factors can have a significant role in complication occurrence.