Excellent Neurological Outcome Research Articles

Outcome of Posterior Lumbar Interbody Fusion (PLIF) with Cage and Bone Graft in The Treatment of Degenerative Lumbar Spinal Canal Stenosis

Introduction: Posterior lumbar interbody fusion (PLIF) is a reliable treatment option for patients with Lumbar canal stenosis & spondylolisthesis; providing spinal stabilization in a balanced alignment with the disc space height restored and with the neural elements being decompressed mechanically. The titanium cages provided immediate stability to spinal levels, restoration of the disc space and neuro-foraminal area, and an increased surface area leading to successful fusion. Materials and Methods: This prospective study was carried out at the Department of Orthopedic Surgery at DMCH, Dhaka within the defined period. All the data were compiled and sorted properly and the quantitative data was analyzed statistically by using Statistical Package for Social Science. The results were expressed as percentage and mean ± SD and p<0.05 was considered as the level of significant. Result: Mean age of the study population was 51.32±8.29 with a female: male ratio 1.6 :1 where maximum patient was housewife (57.14%). 60.72% patients had only single level involvement while 39.28% patients had multi-level involvement. Mean VAS score reduced significantly at final follow-up (6.55±0.66 to 2.29±0.46 for back pain and 6.59±0.65 to 1.21±0.42 for leg pain. Mean ODI score decreased significantly from 56.71±3.09 to 15.82±3.46 at final follow-up. Radiologically Grade-I fusion achieved in 89.28% cases. Overall functional outcome was excellent (89.29%) & good (7.14%) according to Modified Macnab criteria. Conclusion: Posterior lumbar interbody fusion (PLIF) with cage and bone graft in the treatment of degenerative lumbar spinal canal stenosis provides excellent neurological and functional outcome and fusion rate at final follow-up. Medicine Today 2024, Vol.36 (2): 72-75

Case report: Tenecteplase for acute ischemic stroke after heparin reversal

Intravenous thrombolysis can be administered to appropriate patients with suspected acute ischemic strokes who are on intravenous heparin infusions after its rapid reversal with protamine sulfate. Several case reports suggest the safety of tissue-type plasminogen activator, or alteplase, in these scenarios. Noting the increasing preferential use of tenecteplase over alteplase for intravenous thrombolysis of acute ischemic stroke, the safe and efficacious use of tenecteplase following heparin reversal has not been demonstrated in the literature. Our case demonstrates successful use of intravenous tenecteplase in a patient who was anticoagulated with therapeutic heparin. The patient had no hemorrhagic complications and had an excellent neurological outcome.

Surgical Treatment of Complex Craniofacial Fractures

Severe craniofacial fractures may present different needs in treating intracranial lesions over facial injuries. This paper examines the results of our strategy, consisting of a single-stage combined neurosurgical-maxillofacial treatment. A retrospective review was conducted of 33 consecutive patients with complex fractures of the anterior cranial fossa and facial skeleton, who required elective surgery for craniofacial reconstruction. Patients who required emergency surgery for intracranial clots or penetrating wounds were excluded. In all cases, all or almost all the anterior skull-base was injured with compound fractures of the frontal sinus, the orbital roofs, the lamina cribrosa, and the planum sphenoidale. In all cases, the prioritization of treatment was carefully discussed, and surgical timing and strategy were agreed. There was one dead. Olfactory injuries were always found intraoperatively. There were no mucoceles, CSF-leak recurrences, cranial infections, or neurological worsening. The functional and neurological results were highly satisfactory. The one-stage surgical treatment of complex craniofacial fractures has numerous advantages, including the possibility of reducing facial fractures without the risk of CSF leaks. It also eliminates the need for repeated procedures in fragile patients, and the need to dismantle the facial reconstruction if the skull base repair is performed later. The main issue is the surgical timing, considering that the maxillofacial surgeon usually favors early facial repair, whereas the neurosurgeon generally prefers delayed manipulation of the contused frontal lobes. A timeframe of 10-14 days after trauma may be a good compromise for safe procedures with excellent neurological and functional outcomes.

Tenecteplase to Replace Alteplase? Comparing Thrombolytic Therapies for Acute Ischemic Stroke: June 2023 Annals of Emergency Medicine Journal Club.

Tenecteplase to Replace Alteplase? Comparing Thrombolytic Therapies for Acute Ischemic Stroke: June 2023 Annals of Emergency Medicine Journal Club.

The association between stress hyperglycemia and unfavorable outcomes in patients with anterior circulation stroke after mechanical thrombectomy.

Stress hyperglycemia is common in critical and severe diseases. However, few studies have examined the association between stress hyperglycemia and the functional outcomes of patients with anterior circulation stroke, after mechanical thrombectomy (MT), in different diabetes status. This study therefore aimed to determine the relationship between stress hyperglycemia and the risk of adverse neurological functional outcomes in anterior circulation stroke patients with and without diabetes after MT. Data of 408 patients with acute anterior circulation stroke treated with MT through the green-channel treatment system for emergency stroke at the First Affiliated Hospital of Jinan University between January 2016 and December 2020 were reviewed retrospectively. The stress hyperglycemia ratio (SHR) was calculated as fasting plasma glucose (mmol/L) divided by glycosylated hemoglobin (%). The patients were stratified into four groups by quartiles of SHR (Q1-Q4). The primary outcome was an excellent (nondisabled) functional outcome at 3 months after admission (modified Rankin Scale score of 0-1). The relationship between stress hyperglycemia and neurological outcome after stroke was assessed using multivariate logistic regression. After adjusting for potential confounders, compared with patients in Q1, those in Q4 were less likely to have an excellent outcome at 3 months (odds ratio [OR], 0.32, 95% confidence interval [CI], 0.14-0.66, p = 0.003), a good outcome at 3 months (OR, 0.41, 95% CI, 0.20-0.84, p = 0.020), and major neurological improvement (OR, 0.38, 95% CI, 0.19-0.73, p = 0.004). Severe stress hyperglycemia increased risks of 3-months all-cause mortality (OR, 2.82, 95% CI, 1.09-8.29, p = 0.041) and ICH (OR, 2.54, 95% CI, 1.21-5.50, p = 0.015). Stress hyperglycemia was associated with a reduced rate of excellent neurological outcomes, and increased mortality and ICH risks in patients with anterior circulation stroke after MT regardless of diabetes status.

Thoracic spinal angiomyolipoma: case report from an Ethiopian neurosurgical teaching hospital. Illustrative case.

Angiomyolipoma (AML) of the spine is a rare benign neoplasm (accounting for 0.14%-1.2% of all spine tumors) that is often described along with angiolipoma because of their similarities. They occur almost exclusively in the extradural space, with the thoracic spine being the commonest level. The authors present the clinical presentation, diagnosis, and treatment of an extremely rare case of thoracic spine AML in a 47-year-old male patient. The patient underwent laminectomy and gross total resection of the tumor and had an excellent immediate postoperative neurological recovery and long-term functional neurological outcome. It is always wise to consider rare benign spinal epidural neoplasms such as spinal AMLs in the differential diagnosis of spinal epidural mass, despite metastasis being the commonest epidural tumor with variable modes of treatment, because the management of benign spinal epidural masses such as spine AML is always surgical and associated with an excellent long-term outcome.

Successful Treatment of Fulminant Myocarditis with Intracardiac Thrombus in COVID-19

IntroductionThe treatment of pediatric patients with COVID-19 associated myocardial injury and prothrombotic coagulation derangements remains to be established. We cared for an adolescent with COVID-19 and fulminant myocarditis who required veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Her course was complicated by a large intracardiac thrombus, which was successfully treated with systemic tissue plasminogen activator (tPA).Case ReportA 17 year old unvaccinated female presented with fever and chest pain 7 days after testing positive for COVID-19. She had a peak troponin of 21.48 ng/ml, elevated brain natriuretic peptide (629 pg/ml), and severely diminished left ventricular systolic function. She progressed to cardiogenic shock and was cannulated to VA-ECMO via the neck. On ECMO day 2 while therapeutic on unfractionated heparin (UFH), a large thrombus was noted in the left ventricular apex, extending toward the aortic valve (Figure 1). Prior to this, she had no evidence of a deep vein thrombosis. Given the concern for an impending stroke upon restoration of ventricular function, a continuous systemic high-dose tPA infusion (0.1mg/kg/hr) was initiated, while she was continued on UFH. A twenty-fold increase in D-dimer levels and serial echocardiograms indicated a thrombolytic effect. After 22 hours of thrombolysis, the patient developed bleeding complications and tPA was discontinued. By ECMO day 4, the thrombus completely resolved. Once her bleeding was controlled, she was transitioned to bivalirudin. Cardiac function recovered by day 11 allowing for separation from ECMO. 25 days later, she was discharged without any neurologic deficits.SummaryThe coagulopathic derangements associated with COVID -19 pose significant challenges to the management of fulminant myocarditis. There are no guidelines regarding management of an intracardiac thrombus on ECMO. However, with careful monitoring, systemic tPA can be used to provide life-saving therapies with excellent neurological outcomes.

Effect of Intra-arterial Alteplase vs Placebo Following Successful Thrombectomy on Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke

<h3>Importance</h3> It is estimated that only 27% of patients with acute ischemic stroke and large vessel occlusion who undergo successful reperfusion after mechanical thrombectomy are disability free at 90 days. An incomplete microcirculatory reperfusion might contribute to these suboptimal clinical benefits. <h3>Objective</h3> To investigate whether treatment with adjunct intra-arterial alteplase after thrombectomy improves outcomes following reperfusion. <h3>Design, Setting, and Participants</h3> Phase 2b randomized, double-blind, placebo-controlled trial performed from December 2018 through May 2021 in 7 stroke centers in Catalonia, Spain. The study included 121 patients with large vessel occlusion acute ischemic stroke treated with thrombectomy within 24 hours after stroke onset and with an expanded Treatment in Cerebral Ischemia angiographic score of 2b50 to 3. <h3>Interventions</h3> Participants were randomized to receive intra-arterial alteplase (0.225 mg/kg; maximum dose, 22.5 mg) infused over 15 to 30 minutes (n = 61) or placebo (n = 52). <h3>Main Outcomes and Measures</h3> The primary outcome was the difference in proportion of patients achieving a score of 0 or 1 on the 90-day modified Rankin Scale (range, 0 [no symptoms] to 6 [death]) in all patients treated as randomized. Safety outcomes included rate of symptomatic intracranial hemorrhage and death. <h3>Results</h3> The study was terminated early for inability to maintain placebo availability and enrollment rate because of the COVID-19 pandemic. Of 1825 patients with acute ischemic stroke treated with thrombectomy at the 7 study sites, 748 (41%) patients fulfilled the angiographic criteria, 121 (7%) patients were randomized (mean age, 70.6 [SD, 13.7] years; 57 women [47%]), and 113 (6%) were treated as randomized. The proportion of participants with a modified Rankin Scale score of 0 or 1 at 90 days was 59.0% (36/61) with alteplase and 40.4% (21/52) with placebo (adjusted risk difference, 18.4%; 95% CI, 0.3%-36.4%;<i>P</i> = .047). The proportion of patients with symptomatic intracranial hemorrhage within 24 hours was 0% with alteplase and 3.8% with placebo (risk difference, −3.8%; 95% CI, −13.2% to 2.5%). Ninety-day mortality was 8% with alteplase and 15% with placebo (risk difference, −7.2%; 95% CI, −19.2% to 4.8%). <h3>Conclusions and Relevance</h3> Among patients with large vessel occlusion acute ischemic stroke and successful reperfusion following thrombectomy, the use of adjunct intra-arterial alteplase compared with placebo resulted in a greater likelihood of excellent neurological outcome at 90 days. However, because of study limitations, these findings should be interpreted as preliminary and require replication. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT03876119; EudraCT Number:2018-002195-40

Intraspinal Multiple Hereditary Exostosis with Thoracic Myelopathy: A Case Report

Osteochondromas are the most common benign bone tumor and spinal involvement is not uncommon. We report a case of osteochondroma in a 14-year-old girl with underlying multiple hereditary exostosis who presented with thoracic myelopathy symptoms and signs. Magnetic resonance imaging and computed tomography scan revealed intraspinal exostosis causing significant spinal cord compression at the thoracic vertebra. Our patient was treated surgically for exostoses and showed excellent functional and neurological outcomes. The purpose of the report is to share our experience in managing intraspinal exostosis and to emphasize the importance of spinal imaging evaluation in multiple hereditary exostosis patients.

MSC Secretome as a Promising Tool for Neuroprotection and Neuroregeneration in a Model of Intracerebral Hemorrhage.

Multipotent mesenchymal stromal cells (MSCs) are considered to be critical contributors to injured tissue repair and regeneration, and MSC-based therapeutic approaches have been applied to many peripheral and central neurologic disorders. It has been demonstrated that the beneficial effects of MSC are mainly mediated by the components of their secretome. In the current study, we have explored the neuroprotective potential of the MSC secretome in a rat model of intracerebral hemorrhage and shown that a 10-fold concentrated secretome of human MSC and its combination with the brain-derived neurotrophic factor (BDNF) provided a better survival and neurological outcome of rats within 14 days of intracerebral hemorrhage compared to the negative (non-treated) and positive (BDNF) control groups. We found that it was due to the ability of MSC secretome to stimulate neuron survival under conditions of glutamate-induced neurotoxicity. However, the lesion volume did not shrink in these rats, and this also correlated with prominent microglia activation. We hypothesize that this could be caused by the species-specificity of the used MSC secretome and provide evidence to confirm this. Thus, we have found that allogenic rat MSC secretome was more effective than xenogenic human MSC secretome in the rat intracerebral hemorrhage model: it reduced the volume of the lesion and promoted excellent survival and neurological outcome of the treated rats.

Ophthalmoplegia in the Acute Phase of Hemolytic Uremic Syndrome: A Case Report

Hemolytic uremic syndrome (HUS) is a common form of thrombotic microangiopathies. Among its extrarenal complications, ocular involvement is very rare. We present a patient with HUS, whose first symptom was isolated abduction deficits in the eyes. Lethargy was added during the clinical course, suggesting neurological involvement. Although conventional magnetic resonance imaging was normal, symmetric diffusion restriction was detected in bilateral putamen on diffusion-weighted images. Treatment with peritoneal dialysis, fresh frozen plasma infusions, and eculizumab was initiated. The patient responded well to the treatment and was discharged with excellent neurological, hematological, and ophthalmological outcomes. Nephrological follow-up is being continued due to proteinuria To our knowledge, presenting with ophthalmoplegia in the acute phase of hemolytic uremic syndrome is very rare. The patient’s ophthalmological and neurological symptoms improved after eculizumab treatment. We suggest that eculizumab is effective in the acute phase of HUS in cases of ophthalmological involvement.

Acute carbamazepine toxicity in a child: A case report

Carbamazepine is a commonly prescribed antiepileptic drug with a potential to cause fatal toxicity in acute overdose in children. Symptoms of acute toxicity include central nervous system depression, seizures, anticholinergic toxidrome, and arrhythmias. We report a 5 year old male child with accidental carbamazepine toxicity treated sussessfully with good suppotrive management. Intestinal decontamination therapies may be beneficial if used at the appropriate time. Multidose activated charcoal may be used if multiple controlled release tablets are ingested. Extracorporeal therapies for drug removal may be required in life-threatening toxicity to reduce plasma drug levels and hasten recovery. Appropriate and timely management leads to excellent neurological outcome.

Performance evolution over 645 acute stroke thrombectomies in a public Brazilian healthcare institution.

Assessment of the impact of the thrombectomy learning curve on clinical outcomes is essential for developing healthcare system protocols. The aim of this study was to assess the effect of thrombectomy case volume on procedural and clinical outcomes in a Brazilian registry. A total of 645 patients with acute ischemic stroke treated by thrombectomy were included in the analysis. Patients were divided into two groups regarding the period of treatment: the early period group and the late period group. In the adjusted analysis, treatment in the late period was an independent predictor of recanalization (odds ratio 1.91, 95% CI 1.28-2.86) and excellent neurologic outcomes at three months (odds ratio 1.77, 95% CI 1.04-3.01). Treatment in the late period had no significant association with mortality (odds ratio 0.88, 95% CI 0.55-1.41). An increase in thrombectomy case volume for the treatment of AIS over time was an independent predictor of recanalization and excellent neurologic outcome.

Infected congenital cervical dermal sinuses leading to spinal cord abscess: two case reports and a review of the literature

PurposeCongenital dermal sinuses are a rare form of spinal dysraphism. The developmental defects are located along the midline neuroaxis, with sinuses in the cervical region being the least common. Congenital dermal sinuses can be associated with intraspinal infection as they act as a direct route from the skin and subcutaneous tissues into the spinal cord.MethodsThe authors present two cases of cervical dermal sinuses complicated by intramedullary abscess. Both children presented with neurological decline and febrile illness. MRI showed intraspinal abscess. Both underwent prompt surgical excision of the sinus tract, exploration of the cord and intravenous antibiotics.ResultsBoth patients demonstrated excellent neurological recovery.ConclusionsComplete surgical excision of the sinus and tract in addition to long-term antimicrobials can yield excellent neurological outcomes. At surgery, do not expect to find pus when exploring the intramedullary component. Long-term follow-up is advocated due to potential late recurrence.

The Broad Clinical Spectrum and Transplant Results of PNP Deficiency.

Purine nucleoside phosphorylase (PNP) is a known yet rare cause of combined immunodeficiency with a heterogeneous clinical presentation. We aim to add to the expanding clinical spectrum of disease, and to summarize the available data on bone marrow transplant for this condition. Data was collected from patient files retrospectively. A review of the literature of hematopoietic stem cell transplantation (HSCT) for PNP deficiency was conducted. Four patients were treated in two centers in Israel. One patient died of EBV-related lymphoma with CNS involvement prior to transplant. The other three patients underwent successful HSCT with good immune reconstitution post-transplant (follow-up 8-108 months) and excellent neurological outcomes. PNP is a variable immunodeficiency and should be considered in various clinical contexts, with or without neurological manifestations. HSCT offers a good treatment option, with excellent clinical outcomes, when preformed in a timely manner.

Profound cerebral cooling in an OHCA patient leads to an excellent neurological outcome after &gt;10 h of ventricular fibrillation on eCPR

We here report a 40-year-old patient suffering from OHCA due to toxic drug abuse. Despite an unknown length of no- or slow-flow time on persisting ventricular fibrillation, the argument for the implantation of an ECLS was his juvenile age, lack of co-morbidities and severe hypothermia (26°C). In the following days, despite of a cerebral oedema this patient achieved a complete neurological regeneration without any clinical deficiencies and was discharged 17 days after admission. Even though the routine use of extracorporal life support systems (ECLS) i.e. va-ECMO as part of an eCPR in Out-of-Hospital Cardiac Arrest (OHCA) patients is not yet recommended by the current guidelines, some tertiary care centrers provide good evidence for eCPR therapy in these OHCA patients. The lack of randomized controlled trials confuses this scenario in general but locoregional clinical algorithms and hospital cooperation such as cardiac arrest center networks will help to stratify and guide these patients to the right place at the right time and thereby improve clinical outcome for these patients with normally poor prognosis. This latter is true for those patients selected by clinical parameters such as an initially shockable rhythm, low no-flow time and a successful bystander CPR which favour for an early initiation of an eCPR therapy. Moreover, young age (&lt;65years), pH &gt;7.0 and serum lactat &lt;2 mmol/l support us in our decision making to initiate eCPR treatment in an otherwise complete insecure situation.

Successful mechanical thrombectomy in stroke with thrombolysis-associated intracerebral hemorrhage—a case report

BackgroundIntravenous thrombolysis and mechanical thrombectomy are the standard of care for patients with acute ischemic stroke with large vessel occlusion. Intracerebral hemorrhage is a main complication of intravenous thrombolysis, however, no data are available on the efficacy and safety of mechanical thrombectomy in patients with thrombolysis-associated intracerebral hemorrhage. This constellation is expected to become more frequent as increasing numbers of patients are treated under the drip-and-ship paradigm. Case reportA 75-year-old male patient was admitted to an emergency department with acute onset dysarthria and left side hemiparesis due to right middle cerebral artery occlusion. Intravenous thrombolysis was initiated and the patient transferred to our center for mechanical thrombectomy. Upon arrival, cerebral imaging showed persistent right middle cerebral artery occlusion and new onset left frontal, temporal, and parietal intracerebral hemorrhage. Thrombectomy was performed and perfusion completely re-established with excellent neurological outcome. Follow-up imaging revealed probable cerebral amyloid angiopathy. ConclusionMechanical thrombectomy may be safe and effective in ischemic stroke with large vessel occlusion and thrombolysis-associatied intracerebral hemorrhage.

Descending Branch of the Lateral Circumflex Femoral Artery Graft for Posterior Inferior Cerebellar Artery Revascularization.

Posterior inferior cerebellar artery (PICA) revascularization can be achieved with relative ease when a contralateral PICA is present. However, without a contralateral PICA, identification of a suitable vessel alternative can be challenging due to a size mismatch. To propose the descending branch of the lateral circumflex femoral artery (DLCFA) to be an acceptable, if not preferred, arterial graft for PICA revascularization. Data from patients who underwent PICA revascularization with DLCFA grafts were obtained from an institutional review board-approved prospectively maintained database with informed consent from the patients. Three patients, all presenting with ruptured aneurysms, were treated with PICA revascularization using the DLCFA. All cases achieved bypass patency and no ischemic events occurred during the bypass procedures. Graft spasm occurred in 2 patients. Two patients that presented with neurological deficits achieved excellent neurological outcomes and 1 suffered an anterior spinal artery stroke during a repeat endovascular treatment 1 wk after revascularization. The DLCFA is favorable for PICA revascularization when a contralateral PICA is not a viable option.

Successful Treatment of Refractory Cardiac Arrest With β-Blockade and Extracorporeal Life Support in a Pediatric Patient With Catecholaminergic Polymorphic Ventricular Tachycardia: A Case Report

We describe a case of refractory pulseless polymorphic ventricular tachycardia successfully treated with a bolus of propranolol intravenously, followed by an esmolol infusion and extracorporeal life support for 4 days in a 12-year-old boy later diagnosed with catecholaminergic polymorphic ventricular tachycardia. He had an excellent neurological outcome. Genetic testing for mutations associated with cardiac arrhythmias yielded a mutation of the syntrophin α-1 gene. The pathogenicity of this specific variant is uncertain. A mutation of this gene at a different locus is implicated in rare cases of long-QT syndrome. The patient subsequently underwent left cardiac sympathetic denervation followed by implantable cardiac defibrillator insertion. He remains symptom and arrhythmia free on atenolol.

Reducing Door-to-Reperfusion Time for Mechanical Thrombectomy With a Multitiered Notification System for Acute Ischemic Stroke.

ObjectiveTo reduce door-to-angiographic reperfusion (DTR) time to 120 minutes for patients presenting with acute ischemic stroke attributed to anterior circulation large-vessel occlusion amenable to endovascular mechanical thrombectomy.Patients and MethodsPatients treated with mechanical thrombectomy before (April 10, 2015, through April 11, 2016) and after (April 12, 2016, through May 10, 2017) implementation of a multitiered notification system were studied. Lean process mapping was used to assess inefficiencies with multidisciplinary triage. A 3-tiered paging platform, which rapidly alerts essential personnel of the acute ischemic stroke team at advancing decision points, was introduced.ResultsSixty-two patients were analyzed before and after implementation (34 vs 28, respectively). Following intervention, DTR time was reduced by 43 minutes (mean DTR, 170 minutes vs 127 minutes; P=.02). At 90-day follow up, 5 of the 28 patients in the postintervention cohort (19%) had excellent neurologic outcomes, defined as a modified Rankin Scale score of 0, compared to 0 of 34 (0%) in the preintervention cohort (P=.89). Reductions were also seen in the length of stay on the neurocritical care service (mean, 6 vs 3 days; P=.006), and total hospital charges for combined groups (mean, $100,083 vs $161,458; P<.001).ConclusionThe multitiered notification system was a feasible solution for improving DTR within our institution, resulting in reductions of overall DTR time, neurocritical care service length of stay, and total hospital charges.