Exacerbation Of Neurological Symptoms Research Articles

Intraoperative DSA-guided minimal approach for craniocervical junction DAVFs obliteration.

Dural arteriovenous fistulas (DAVFs) are a group of diseases involving problematic shunts between dural arteries and venous structures such as sinuses, meningeal veins, or even cortical veins. To focus on craniocervical junction dural arteriovenous fistulas (DAVFs), we introduce a minimally invasive technique with midline incision combined with intraoperative digital subtraction angiography (DSA). This hybrid technique can minimize the incision wound to an average of 6 cm which leads to less destruction and lower risk of adverse events. Using this minimally invasive approach, surgical obliteration was achieved in 6 patients with craniocervical junction DAVFs. A minimal midline incision was made over the C1-2 level, measuring approximately 5 to 7 cm in length. C1 hemilaminectomy was performed for DAVF obliteration followed by intraoperative DSA for confirmation of complete obliteration. Among these 6 patients, the radiculomedullary artery was the most common feeding artery. The mean length of the operation (including DSA performance) was 6.5 ± 1.4 h. None of these cases showed cerebrospinal fluid leakage or exacerbation of neurological symptoms after the operation. Using intraoperative DSA, the minimally invasive technique offers more precise but less destructive access than conventional far lateral suboccipital craniotomy. Most importantly, intraoperative DSA provided verification of complete closure for shunts that could not be examined for indocyanine green (ICG) dye because the microscope did not have a clear line of sight. In our experience, this technique shows encouraging results of fistula obliteration.

A Validated HPLC-MS/MS Method for Quantification of Fingolimod and Fingolimod-Phosphate in Human Plasma: Application to Patients with Relapsing–Remitting Multiple Sclerosis

Fingolimod is a sphingosine 1-phosphate-receptor modulator approved for the oral treatment of relapsing–remitting multiple sclerosis (RRMS), a form of MS characterized by a pattern of exacerbation of neurological symptoms followed by recovery. Here, we validated a simple and rapid liquid chromatography–tandem mass spectrometry method for the measurement of the concentrations of Fingolimod and its active metabolite Fingolimod-Phosphate (Fingolimod-P) in human plasma. The lower limits of quantification were set at 0.3 and 1.5 ng/mL for Fingolimod and Fingolimod-P, respectively, and the linearity was in the range 0.3–150 ng Fingolimod/mL and 1.5–150 ng Fingolimod-P/mL. After protein precipitation, the extraction recoveries of both analytes were always above 60% with minimal matrix effect. The method was accurate and precise, satisfying the criteria set in the European Medicine Agency guidelines for bioanalytical method validation. The method was then applied to measure Fingolimod and Fingolimod-P concentrations in the plasma of 15 RRMS patients under chronic treatment with Fingolimod, administered daily at the dose of 0.5 mg for up to 24 months. No significant differences were observed between samples collected at 6, 12 and 24 months for both analytes, indicating that the drug’s bioavailability was unaffected by multiple daily doses up to 24 months. The levels of Fingolimod-P were about two-fold higher than the levels of the parent compound. The availability of this analytical method can allow the monitoring of the impact of plasma levels of the drug and its metabolite on inter-individual variability in clinical responses.

Surgical and Neurological Outcome of Minimally Invasive Thymectomy in Patients With Myasthenia Gravis: An Experience of 100 Cases Over 6 Years at a Tertiary Care Center in North India.

Minimally invasive thymectomy (MIT) is emerging as an effective alternative to open thymectomy in the management of patients with myasthenia gravis (MG). The primary objective of our study is to assess the surgical and neurological outcome of MIT in patients with MG. It is a retrospective evaluation of prospectively collected data of 100 patients with MG, who underwent MIT from April 2012 to January 2018 at a tertiary care center in India. Surgical outcome was assessed for success of minimal invasive approach, conversion, perioperative morbidity, and postoperative hospital course. Neurological outcome was assessed, after at least 1 year of follow-up, according to Myasthenia Gravis Foundation of America postintervention status. Factors predicting complete stable remission (CSR) were evaluated. MIT was successfully performed in 98% patients with 2% conversion. There was no mortality. Overall, 10% of patients had perioperative morbidity with 5% having exacerbation of neurological symptoms. Two of these needed postoperative ventilation, whereas 3 recovered on conservative treatment. Median operative time and hospital stay were 140 minutes and 3 days, respectively. At a median follow-up of 47 months, CSR was seen in 20% with improvement in 73.3%. Overall, 63% patients were taken off steroids and patients requiring 3 drugs decreased by 70.7%. There was significant reduction in the dosage of pyridostigmine (P<0.001), prednisolone (P<0.001), and azathioprine (P=0.002) after thymectomy. Milder disease (Myasthenia Gravis Foundation of America class 1 and 2) predicted CSR on multivariate analysis. MIT is a safe and effective procedure that leads to improvement in neurological status with significant reduction in number and dosage of medications after thymectomy. Mild disease predicts CSR.

Isolated Sciatic Nerve Endometriosis

Study Objective Sciatic Nerve Endometriosis is rarely observed. Symptoms include sciatica, gluteal pain, and sometimes, locomotion problems without bladder dysfunction or Pudendal pain. Clinical gynecological pelvic examination in these patients is usually unremarkable. Design Case report with surgical technical details and anatomical landmark discussion. Setting Gynecologic Endoscopic Unit in a Tertiary Care Private Clinic. Patients or Participants 46-year-old patient with multiple leiomyomas and chronic pelvic pain. 3 years with progressive sciatic pain (right hip and buttock pain), alteration of sensation along L5 and S1 dermatomes with a perceived reduced power in the right ankle. All showed severe exacerbation during menstruation. Besides uteromegaly, her pelvic gynecological examination was normal. Pelvic MRI showed a 3.4 cm endometriotic lesion over the pelvic segment of her right sciatic nerve, before exiting the great sciatic foramen. Interventions Laparoscopic access to the Lumbosacral space and sciatic nerve cold scissors shaving. Measurements and Main Results The patient recovered well from her surgery. She complained of exacerbation of neurological symptoms immediately after surgery, specifically lower limb paresthesia over the first few days. After a week she had significant improvement of pain and after one year she is asymptomatic. Conclusion Exploration of lumbosacral space should not be undertaken lightly due to its complex anatomy and potential for serious injury to the major neurovascular structures. Once the procedure is started, resection of the lesions must be fully completed to avoid further surgical interventions which are always more challenging than the preceding one.

Conservative and Surgical Management of Spinal Cord Cavernous Malformations

ObjectivesWe present a case series of spinal cord cavernous malformations (SCCMs) to describe clinical presentation and outcomes of both surgical and conservative management.MethodsThe clinical courses of patients diagnosed with SCCMs at our institution were retrospectively reviewed. Neurologic symptoms were evaluated using the Modified McCormick Scale.ResultsA total of 18 patients were identified. Five patients (27.8%) presented with acute onset bleeding, 4 of whom underwent immediate surgical resection. Thirteen patients (72.2%) were initially managed conservatively. Eight patients (38.9%) developed a hemorrhage during follow-up, and 8 (38.9%) required surgical resection due to bleeding or neurological worsening. The mean (range) duration from primary symptoms to subsequent hemorrhage or deterioration of symptoms was 1.42 (range: 0.25–4.33) years. The mean duration from primary symptoms to surgery was 2.10 (range: 0.25–5.0) years. No patients experienced subsequent hemorrhage after surgical resection. Eleven patients (84.6%) in the surgery group showed improved neurological status, and 2 patients (15.4%) remained unchanged. The annualized subsequent hemorrhage risk was 3.7%. Patients in the immediate surgical group had a significantly larger lesion compared with those in the conservative group. There was significance between the worst Modified McCormick Scale grades at the time of debilitating symptoms and the length of hemorrhage, but not the size of the lesion.ConclusionsSurgery for SCCMs resulted in no recurrence of hemorrhage or exacerbation of neurological symptoms, and should be considered for patients who experienced acute onset of hemorrhage or debilitating symptoms during follow-up.

Inline flow sensor for ventriculoperitoneal shunts: Experimental evaluation in swine

Shunts are commonly employed to treat hydrocephalus, a severe central nervous disease caused by the buildup of cerebrospinal fluid in the brain. These shunts divert excessive cerebrospinal fluid from brain ventricles to other body cavities, thereby relieving the symptoms. However, these shunts are highly prone to failure due to obstruction from cellular debris, leading to cerebrospinal fluid accumulation in the brain and exacerbation of neurological symptoms. Therefore, there is a clinical need for a reliable, non-invasive method of monitoring shunt performance. Recently, a simple inline flow sensor was reported for monitoring ventriculoperitoneal shunting of cerebrospinal fluid in hydrocephalus treatment. The present work aimed to evaluate performance of the device in an animal model of hydrocephalus. Sensor-equipped shunt tubes were placed in anesthetized, juvenile swine. The flows reported by the sensor were compared with gravimetric flow measurements. Robust correlations (r ≈ 0.87–0.96) between the gravimetric and sensor-reported flows were obtained in 4 of the 6 experiments. The mean slope of the linear relationship of the gravimetrically determined vs. sensor flow rates was 0.98 ± 0.09 in the 6 experiments, indicating the sensor accurately reported shunt flows up to 35 ml/h. The sensor responded immediately to abrupt flow changes following cerebroventricular fluid injections. Minor hardware problems were identified and corrected. These experiments provide practical guidance for future preclinical testing of the device.

Radiological evolution of porcine neurocysticercosis after combined antiparasitic treatment with praziquantel and albendazole.

BackgroundThe onset of anthelmintic treatment of neurocysticercosis (NCC) provokes an acute immune response of the host, which in human cases is associated with exacerbation of neurological symptoms. This inflammation can occur at the first days of therapy. So, changes in the brain cysts appearance may be detected by medical imaging. We evaluated radiological changes in the appearance of brain cysts (enhancement and size) on days two and five after the onset of antiparasitic treatment using naturally infected pigs as a model for human NCC.Methods and resultsContrast T1-weighted magnetic resonance imaging with gadolinium was performed before and after antiparasitic treatment. Eight NCC-infected pigs were treated with praziquantel plus albendazole and euthanized two (n = 4) and five (n = 4) days after treatment; another group of four infected pigs served as untreated controls. For each lesion, gadolinium enhancement intensity (GEI) and cyst volume were measured at baseline and after antiparasitic treatment. Volume and GEI quantification ratios (post/pre-treatment measures) were used to appraise the effect of treatment. Cysts from untreated pigs showed little variations between their basal and post treatment measures. At days 2 and 5 there were significant increases in GEI ratio compared with the untreated group (1.32 and 1.47 vs 1.01, p = 0.021 and p = 0.021). Cyst volume ratios were significantly lower at days 2 and 5 compared with the untreated group (0.60 and 0.22 vs 0.95, p = 0.04 and p = 0.02). Cysts with lower cyst volume ratios showed more marked post-treatment inflammation, loss of vesicular fluid and cyst wall wrinkling.Conclusion/SignificanceA significant and drastic reduction of cyst size and increased pericystic enhancement occur in the initial days after antiparasitic treatment as an effect of acute perilesional immune response. These significant changes showed that early anthelmintic efficacy (day two) can be detected using magnetic resonance imaging.

Inflammation Inducing Central Nervous System Damage in HTLV-1 Infection

Human T-cell lymphotropic virus type 1 (HTLV-1) is involved with two well-described clinical conditions: HTLV-1-associated myelopathy/ tropical spastic paraparesis (HAM/TSP) and adult T cell leukemia. The neurological disease affects predominantly the spinal cord. Although unusual, the brain as well as other organs may be involved by inflammatory reaction associated with HTLV-1 infection. This condition was recently described in our report “Temporal lesions and widespread involvement of white matter associated with multi-organ inflammatory disease in human T-lymphotropic virus type 1-associated myelopathy/tropical spastic paraparesis (HAM/TSP)”. The development of HTLV-1-associated diseases seems to be regulated by viral, host and environmental determinants. High proviral load (PVL) is the best predictor of HAM/TSP. Proviral integration into transcriptionally active units in host genomes and genotypes HLA-B*5401 and HLA-DRB1*0101 are associated with high PVL and consequently linked to HAM/TSP. The increased proliferation and migration of HTLV-1 infected lymphocytes to central nervous system and a resulting strong pro-inflammatory reaction play a crucial role in the neuropathogenesis of the disease. In general, increasing in HTLV-1 PVL in both peripheral blood mononuclear cells and in cerebrospinal fluid (CSF) cells coincides with the exacerbation of neurological symptoms. Analysis of CSF in HAM/TSP shows an inflammatory response characterized by lymphocytic pleocytosis, raised protein content, intrathecal synthesis of oligoclonal IgG bands and of specific IgG, and increased concentration of pro-inflammatory markers. Here, it will be discussed the pathogenesis and the inflammatory mechanisms leading to injury of the central nervous system in HTLV-1 infection.

Reversible Posterior Leukoencephalopathy Syndrome Accompanying Eclampsia: Correct Diagnosis Using Preoperative MRI

Reversible posterior leukoencephalopathy syndrome (RPLS) is characterized by clinical symptoms such as seizures, visual disturbance, and altered mental status. It also presents abnormal findings on computed tomography (CT) and magnetic resonance imaging (MRI) indicating cerebral edema in the white matter of the occipital, temporal, and parietal lobes. Both the clinical symptoms and abnormal imaging findings can be reversed by controlling blood pressure or treating the underlying condition including infection. This report describes a patient with RPLS that occurred secondary to eclampsia. A 26-year-old female, gravida 0 para 0, developed weakness and pain in her upper and lower extremities and gait disturbance during the 34th week of pregnancy, and severe pregnancy-induced hypertension near the end of the 37th week. On the first day of the 38th week, she developed constricted visual fields and complained of visual illusions. MRI revealed a high-signal-intensity area in the right occipital lobe. Immediately after MRI, the patient had a 10-sec tonic convulsion. Diagnosed with eclampsia, she underwent emergency cesarean section. MRI on the 2nd postoperative day showed that the high-signal-intensity area was slightly improved. Her visual illusions were diminished by the 4th postoperative day, and almost all subjective symptoms disappeared by the 7th postoperative day. The patient was discharged at 12th postoperative day. We recommend MRI not only for symptomatic patients with suspected RPLS, but also for asymptomatic patients with severe pregnancy-induced hypertension. If findings such as cerebral edema are observed on MRI, immediate delivery should be considered before eclamptic seizures or exacerbation of neurological symptoms.

P02-105 - Parkinson's disease: Frequency of depressive syndrome

Parkinson's disease is characterized by neurological symptoms: tremor, rigor, bradykinesia and postural instability, but psychical symptoms are also present, most frequent depression and dementia.Depression can precede neurological symptoms of disease, or be manifestation of illness itself. In literature, we find that depression major is represented in 5 – 25% of diagnosed patients, and depressive mood as isolated symptom in 40 – 60%.Purpose of this study was to determine presence of depressive syndrome in patients diagnosed with Parkinson's disease and whether this syndrome is therapeutically sensitive. Study included all patients treated with Parkinson's disease, inmate and outpatients, during the two - year period (from 01.01.2007. up to 31.01.2009.). Hamilton's Depression Rating Scale (HAMD) was used as instrument of clinical assessment for depression, and schedule neurological examinations once a month to evaluate neurological status of patients.Base - line scoring showed that almost 50% of patients had symptoms of depression; it was more frequent in elderly patients, treated with polytherapy. In follow - up period, we assessed patients after three and six months of antidepressive therapy. Results of statistic analysis showed improvement of psychic status of patients, according to HAMD score, in three quarters of followed patients. Exacerbation of neurological symptoms was not observed during the follow - up period.

Combined spinal-epidural anesthesia for caesarian section in a patients with multiple sclerosis: A case report.

The use of neuroaxial blocks in patients with multiple sclerosis has been controversial, because the effect of local anesthetic drugs on the course of the disease is unclear. We report an obstetric patient with multiple sclerosis whose caesarian section was performed successfully under combined spinal-epidural anesthesia and postoperative pain control was managed using patient-controlled epidural analgesia. There were no exacerbation of neurologic symptoms and no relapse of disease at two month follow-up. We suggest that the choice of anesthetic technique for patients with multiple sclerosis should be determined after evaluation of the course of the disease and informed consent. The obstetric patients with multiple sclerosis should not be denied the neuroaxial block for labor and caesarian section.

Asymptomatic Self-Limiting Diffuse White Matter Lesions in Subacute to Chronic Stage of Herpes Simplex Encephalitis

This study evaluated white matter changes in the subacute and chronic stages of herpes simplex encephalitis (HSE). Subjects comprised 15 patients with HSE. All patients were examined using MRI at onset, and then at seven to ten days, three to five weeks and two to three months after onset. In addition, the six patients who displayed white matter signal abnormalities were examined at six months and <one year after onset. Cell count, protein levels, polymerase chain reaction (PCR) of herpes simplex virus in cerebrospinal fluid (CSF), and exacerbation of neurological symptoms as well as dose of acyclovir were compared between patients with and without white matter abnormalities. Diffuse white matter signal changes were identified at the subacute stage (3-5 weeks after onset) of HSE in six patients (6/15, 40%). No significant relationship was observed between the presence of white matter signal abnormalities and laboratory data, acyclovir dose or clinical symptoms. These signal abnormalities disappeared or improved by two years without any clinical treatment. Diffuse white matter signal abnormalities occur frequently in the subacute stage of HSE. Although the mechanisms underlying these white matter lesions have not been elucidated, subclinical immune-mediated processes may be considered. Repeat MRI studies over a long period are necessary for evaluating the clinical process of patients with HSE.

Therapy of parenchymal brain cysticercosis with praziquantel.

Twenty-six patients with cysticercosis of the brain parenchyma were treated with the antihelmintic agent praziquantel (50 mg per kilogram of body weight daily for 15 days). During treatment a strong inflammatory reaction occurred, as evidenced by increased protein and cells in the cerebrospinal fluid. This finding correlated with headache, exacerbation of neurologic symptoms, and edema and inflammation around cystic lesions. After three months of treatment all patients had improved clinically, and 13 (50 per cent) were asymptomatic. The total number of cysts on CT scans had decreased from 152 at the beginning of treatment to 51, and the mean diameter of cysts was reduced by 72 per cent. CT scans showed improvement in 25 of the 26 patients, with total remission of all cysts in nine. Seventeen control patients followed with CT studies for a mean of 9 +/- 2 months had no spontaneous remission of lesions, and in many cases the scans showed worsening during the observation period. Our results indicate that praziquantel is effective in cysticercosis of the brain parenchyma.