Excellent Neurological Recovery Research Articles

Abstract 4145899: The Danger of Moderator Band Ectopy: A Case of Premature Ventricular Contraction induced Recurrent Ventricular Fibrillation

Introduction: Premature Ventricular Contractions (PVCs) are often a benign arrhythmia. However, those originating from the Purkinje system can result in fatal arrhythmias. One example is PVCs originating from the moderator band (MB) within the right ventricle (RV) of the heart. We present a case of PVCs originating from the MB triggering idiopathic ventricular fibrillation (VF) and electrical storm. Case: A previously healthy 49-year-old woman was admitted following a witnessed VF cardiac arrest. She had recurrent episodes of VF, initially treated with Amiodarone and Procainamide which failed to suppress the recurrent VF. She received 54 external defibrillations before a transvenous pacer (TVP) was placed to override the PVCs at a pacing rate of 110 bpm. Post-resuscitation ECGs revealed frequent PVCs originating from the RV free wall, potentially from the lateral part of MB (Figure 1). Quinidine was added to suppress the PVCs ultimately allowing removal of the TVP. Transthoracic Echocardiogram revealed normal cardiac function and a prominent MB. A cardiac MRI was performed showing no infiltrative disease or any other abnormalities. The patient underwent sympathectomy and defibrillator placement. Despite recurrent cardiac arrest, she had excellent neurologic recovery and was subsequently discharged on Quinidine. Discussion: MB extends from the septal wall to the base of the anterior papillary muscle in the RV, carrying Purkinje fibers(PF) from the right bundle branch as it exits the septum. Purkinje fibers have been shown to initiate arrhythmias by several mechanisms including enhanced automaticity, triggered activity and re-entry. In the genesis of PVCs, triggered activity is the likely mechanism. This can degenerate into VF in a structurally normal heart, hence the term “idiopathic VF”. Familiarity with this entity and ECG features of MB ectopy leads to timely management and may potentially prevent lethal arrhythmias in symptomatic patients with such PVCs. Further studies are required to fully understand the arrhythmogenic mechanisms and the optimal management approach for MB ectopy.

Successful management of intracranial hemorrhage with brain herniation in a postpartum patient on extracorporeal membranous oxygenation: A case report.

Managing intracranial hemorrhage in patients supported by extracorporeal oxygenation (ECMO) presents significant clinical challenges. We report a case of a postpartum patient with severe acute respiratory distress syndrome (ARDS) necessitating venovenous ECMO support, complicated by multicompartmental intracranial hemorrhage resulting in brain herniation and necessitating emergent medical and surgical management of refractory intracranial hypertension. Care was guided by multimodal neuromonitoring, including intracranial pressure monitoring and electroencephalography. Despite these challenges, the patient achieved excellent neurological recovery. This case underscores the intricacies of managing neurological complications during ECMO and highlights the potential benefits of comprehensive neuromonitoring strategies.

Endovascular thrombectomy for acute ischemic stroke with a large infarct area: An updated systematic review and meta-analysis of randomized controlled trials

BackgroundSince the efficacy and safety of endovascular thrombectomy (EVT) in patients with acute ischemic stroke with a large infarct area is still inconclusive, we sought to compare functional and neurological outcomes with the use of endovascular thrombectomy versus medical care alone. MethodsWe searched MEDLINE (via PubMed), Embase, Cochrane Library, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP) to retrieve all the relevant randomized controlled trials (RCTs) on this topic. Review manager (RevMan) was used to perform meta-analyses using a random-effect model. Dichotomous outcomes were pooled using risk ratios (RR) with 95% confidence intervals (CIs). ResultsOur meta-analysis included 6 RCTs with a total of 1665 patients. Most studies included patients with an ASPECTS score of 3-5. Our results demonstrate that endovascular thrombectomy significantly increased the rates of functional independence (mRS ≤ 2) (RR, 2.49; 95% CI, 1.89-3.29) and moderate neurological outcome (mRS ≤ 3) (RR, 1.90; 95% CI, 1.50-2.40) at 90 days. The benefit of EVT for these outcomes remained the same at 1-year follow-up. Endovascular thrombectomy was associated with increased rates of early neurological improvement (RR, 2.22; 95% CI, 1.53-3.22), excellent neurological recovery (mRS ≤ 1) (RR, 1.75; 95% CI, 1.02-3.03), and decreased rate of poor neurological recovery (mRS 4-6) (RR, 0.81; 95% CI, 0.76-0.86). No significant difference was found between the two groups regarding all-cause mortality (RR, 0.86; 95% CI, 0.72-1.02), decompressive craniectomy (RR, 1.32; 95% CI, 0.89-1.94), and the incidence of serious adverse effects (RR, 1.39; 95% CI, 0.83-2.32) between the two groups. Endovascular thrombectomy significantly increased the rates of any intracranial hemorrhage (RR, 1.94; 95% CI, 1.48-2.53) and symptomatic intracranial hemorrhage (RR, 1.73; 95% CI, 1.11-2.69). ConclusionEndovascular thrombectomy (EVT) significantly improves neurological and functional outcomes in patients who present within 6 hours of stroke onset with ICA and proximal M1 occlusions, and ASPECTS scores ranging from 3 to 5, compared to medical therapy alone, with an increased risk of symptomatic intracranial hemorrhage.

Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischemic Stroke: a Systematic Review and Meta-Analysis

Background and PurposeOptimal clinical outcome with successful recanalization from endovascular thrombectomy (EVT) requires optimal blood pressure (BP) management. We aimed to evaluate the efficacy and safety of the intensive BP target (< 140 mm Hg) versus the standard BP target (< 180 mm Hg) after EVT for acute ischemic stroke.MethodsWe conducted a systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) obtained from PubMed, Embase Cochrane, Scopus, and WOS until September 7th, 2023. We used the fixed-effect model to report dichotomous outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD), with a 95% confidence interval (CI). PROSPERO ID: CRD42023463206.ResultsWe included four RCTs with 1559 patients. There was no difference between intensive BP and standard BP targets regarding the National Institutes of Health Stroke Scale (NIHSS) change after 24 h [MD: 0.44 with 95% CI (0.0, 0.87), P = 0.05]. However, the intensive BP target was significantly associated with a decreased risk of excellent neurological recovery (mRS ≤ 1) [RR: 0.87 with 95% CI (0.76, 0.99), P = 0.03], functional independence (mRS ≤ 2) [RR: 0.81 with 95% CI (0.73, 0.90), P = 0.0001] and independent ambulation (mRS ≤ 3) [RR: 0.85 with 95% CI (0.79, 0.92), P < 0.0001].ConclusionsAn intensive BP target after EVT is associated with worse neurological recovery and significantly decreased rates of functional independence and independent ambulation compared to the standard BP target. Therefore, the intensive BP target should be avoided after EVT for acute ischemic stroke.

Abstract 13107: Addressing Sudden Cardiac Arrest: An Analysis of the Efficacy and Implementation of Automated External Defibrillators in New Jersey Schools

Introduction: Out of hospital sudden cardiac arrest is a major health concern with a low survival rate. Proper Automated External Defibrillator use has been shown to decrease mortality associated with OHCA. In 2014, New Jersey passed Janet’s Law to mandate automated external defibrillator access in all public and private schools. Our project surveyed NJ schools to evaluate the implementation of AEDs and to analyze their usage and outcomes. Hypothesis: Schools that were adherent to AED placement and training as outlined in Janet’s Law will likely have more positive outcomes from sudden cardiac arrests on school properties than schools that do not. Methods: An observational, cross sectional study was conducted via an online form (Redcap 12.4.2) sent to New Jersey public school nurses. Data was collected from February to June 2023 and analyzed using SAS version 9.4. Results: 301 (99.7%) responses reported having automated external defibrillators. 85.3% of schools provided AED staff training. 42 schools (14.4%) utilized an AED in a cardiac emergency, most often occurring to students in classrooms. An AED was administered by school employees 95.8% of the time. In 80.5% of cases, the patient was resuscitated on scene with no long term neurological complications. 87.2% of schools have an emergency response plan. Conclusions: Our data highlights the impact of proper AED utilization to positively influence out of hospital sudden cardiac arrest outcomes in pediatric populations. Despite Janet’s law being an unfunded mandate, we found near complete compliance among New Jersey schools. The majority of reported sudden cardiac arrests occurred in a classroom setting, necessitating available resources throughout school facilities. In these events, the percentage of positive patient outcomes in our study was significantly higher than the national average with excellent neurological recovery. This discovery may be a product of excellent response rates by trained staff as mandated in Janet’s law. Our findings highlight the need for awareness, training, and accessibility regarding AEDs.

Tenecteplase vs. Alteplase for Intravenous Thrombolytic Therapy of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

In recent years, as one of the drugs for the treatment of acute ischemic stroke (AIS), the clinical application of tenecteplase is still controversial. Therefore, we aimed to evaluate the safety and efficacy of tenecteplase versus alteplase to guide clinical practice. A search of PubMed, MEDLINE, EMBASE, Cochrane Library, and Web of Science databases until February15, 2023 was conducted to identify eligible articles. The quality of the included studies was assessed using the Cochrane Risk of Bias tool. RevMan5.3 and Stata17 were used to perform the meta-analysis and detect publication bias, and risk ratios (RRs) with 95% confidence intervals (95%CIs) were reported for each outcome measure. A total of 1326 records were retrieved in this meta-analysis. As a result of the limited reports on tenecteplase in patients with AIS and the lack of high-quality randomized controlled trials (RCTs), and considering the impact of publication bias, we did not include any of these studies published before 2015. Ultimately we included 16 RCTs with a total of 7508 patients, including 3940 patients treated with alteplase and 3568 patients treated with tenecteplase. Tenecteplase was associated with better early neurological improvement (RR 0.10; 95%CI 0.00-0.19; P = 0.04), recanalization of blood vessels (RR 0.24; 95%CI 0.07-0.40; P = 0.01), and 90-day excellent neurological recovery (RR 0.12; 95%CI 0.01-0.24; P = 0.04). In addition, there were no significant differences in other efficacy and safety outcomes between the two groups. The funnel plot and Begg's as well as Egger's tests showed no significant publication bias. This meta-analysis showed that tenecteplase was not inferior to alteplase in early thrombolytic therapy in patients with AIS, and was even better than alteplase on some efficacy outcomes with no significant differences in safety. However, as a result of some inherent limitations of this study, more high-quality prospective clinical studies are needed to confirm these results.

In retrospective, the gentle learning curve of unilateral laminectomy promotes favorable clinical outcomes

BackgroundThe learning curve in implementing a new surgical procedure is often time-consuming and potentially comes with the additional risk of injury associated with an unusual surgical procedure, which may harm the patient. AimEvaluate intraoperative burden and neurologic recovery of spinal tumor resection following unilateral laminectomy procedures. MethodsMedical records of patients undergoing surgery for intradural spinal tumors from January 2015 to June 2020 were retrospectively reviewed. Preoperative and postoperative data were collected from medical records and interviews. The intraoperative burden was assessed by duration of surgery, estimated intraoperative blood loss (EIBL), and postoperative leukocyte count. Short-term and long-term outcomes were recorded. Data analysis was performed using descriptive statistics and Fisher's exact test. The neurological recovery rate is calculated by the Hirabayashi method, where a 75–100% score indicates an excellent neurological recovery. ResultsTwenty-six records were included in this study. The mean duration of surgery was 180 (120–540) minutes, the mean EIBL was 175 (50 – 1,200) mL, and mean increase in postoperative leukocyte count was 5,670 (2,210 – 13,250) cells/mL, and the mean LOS was 6.5 (4 – 42) days. In 20 of 26 (76.9%) patients, gross total resection was achieved. An excellent neurological recovery rate was achieved in 81% of patients. ConclusionUnilateral laminectomy procedures are adaptable without additional disadvantages, resulting in satisfactory clinical results.

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.

Aneurysmal subarachnoid haemorrhage in Māori and European New Zealanders – A comparative study

A retrospective analysis of 358 patients admitted to the neurosurgical unit at a tertiary referral centre in Aotearoa New Zealand between 2010 and 2017 was undertaken to describe the relationship of ethnicity to demographic, disease characteristic and outcome data in Māori and European New Zealanders experiencing aneurysmal subarachnoid haemorrhage (aSAH). Māori had a higher incidence (RR 1.38, p = 0.01; 95 % CI 1.08–1.77) and presented at a younger age (mean age difference of 5 years). Higher rates of smoking and hypertension were observed in the Māori population studied. However, these do not fully explain any other differences observed. There was no significant difference in clinical grade at presentation. However, despite experiencing lower rates of posterior circulation aneurysms (adjusted OR 0.33, p = 0.05) and radiological findings predicting highest risk of vasospasm i.e., Modified Rankin Scale 4 (OR 0.54, p = 0.02), Māori had a higher incidence of clinical vasospasm (adjusted OR 1.40, p = 0.048, 95 % CI 1.01–1.98). While there was no observed difference in mortality, Māori may experience lower rates of excellent neurological recovery and survive with greater disability compared to European New Zealanders. Overall, this study is suggestive of inequities between Māori and European New Zealanders and highlights the need for further investigation in this area.

Endoscope-assisted far lateral craniotomy for resection of posterior fossa neurocysticercosis: illustrative case.

BACKGROUNDNeurocysticercosis is a parasitic infection that commonly affects the ventricles, subarachnoid spaces, and spinal cord of the central nervous system. The authors report an unusual manifestation of purely posterior fossa neurocysticercosis treated with endoscope-assisted open craniotomy for resection.OBSERVATIONSA 67-year-old male presented with 2 months of progressive dizziness, gait ataxia, headaches, decreased hearing, and memory impairment. Imaging revealed an extra-axial cystic lesion occupying the foramen magnum and left cerebellopontine angle with significant mass effect and evidence of early hydrocephalus. Gross-total resection was accomplished via a left far lateral craniotomy with open endoscopic assistance, and pathological findings were consistent with neurocysticercosis. Postoperatively, he was noted to have a sixth nerve palsy, and adjuvant therapy included albendazole. By 9 months postoperatively, he exhibited complete resolution of an immediate postoperative sixth nerve palsy in addition to all preoperative symptoms. His hydrocephalus resolved and did not require permanent cerebrospinal fluid (CSF) diversion.LESSONSWhen combined with traditional skull base approaches, open endoscopic techniques allow for enhanced visualization and resection of complex lesions otherwise inaccessible under the microscope alone. Recognition and obliteration of central nervous system neurocysticercosis can facilitate excellent neurological recovery without the need for CSF diversion.

327 Tenecteplase Versus Alteplase in Acute Ischemic Stroke: Finding the Correct '-ase' and 'Dosage' Using Network Meta-analysis Approach

327 Tenecteplase Versus Alteplase in Acute Ischemic Stroke: Finding the Correct '-ase' and 'Dosage' Using Network Meta-analysis Approach

Thoracic spine aneurysmal bone cyst causing paraplegia in a child: A case report

A primary aneurysmal bone cyst (ABC) of the spine is a benign lesion with an aggressive nature that can lead to bone destruction and the potential of recurrence after surgical resection. This report focuses on a rare case of the primary ABC in the proximal thoracic spine that is associated with paraplegia in a 7-year-old patient. Nonetheless, the previous research has confirmed that the best therapy for thoracic lesions is challenging and the paucity of evidence-based practice remains an impediment to addressing the issue. The main attribute that leads to these difficulties is the position of the lesions that occur close to the spine and the documented relationship to deformity. Surgical resection decompression can be used alone or in combination with fixation, curettage, selective arterial embolization, and radiotherapy. This report aimed to discuss the clinical, radiological, and therapeutic features of the primary spinal ABC and stress the need for complete surgical excision and decompression if complete spinal cord injury is present. We report this rare case, which was treated surgically with excellent neurological recovery and no recurrence of the ABC at 7 months of follow-up.

Repair of Giant Anterior Skull Base Encephalocele Containing Intralesional Eloquent Brain: Technical Note.

Encephaloceles are herniations of intracranial neural tissue and meninges through defects in the skull. Basal encephaloceles are rare anterior skull base defects incident in 1 in 35,000 live births. Sphenoethmoidal encephaloceles are even more uncommon, with an incidence of 1 in 700,000 live births. Anterior skull base encephaloceles may be life-threatening in infants, presenting as airway obstruction and respiratory compromise. They can also present with cerebrospinal fluid (CSF) rhinorrhea, purulent nasal drainage, or meningitis. To report a novel technique for repairing a giant sphenoethmoidal encephalocele containing eloquent neural tissue. A 16-mo-old girl presented with progressive airway obstruction from a giant sphenoethmoidal encephalocele that filled her oral cavity. She had multiple congenital anomalies including agenesis of the corpus callosum and cleft lip and palate. Computed tomography showed complete absence of the bony anterior cranial base, and magnetic resonance imaging demonstrated the presence of the pituitary gland and hypothalamus in the hernia sac. We repaired the encephalocele using a combined microsurgical and endoscopic multidisciplinary approach working through transcranial, transnasal, and transpalatal corridors. The procedure was completed in a single stage, during which the midline cleft lip was also repaired. The child made an excellent neurological and aesthetic recovery with preservation of pituitary and hypothalamic function, without evidence of CSF fistula. The authors describe a novel multidisciplinary technique for treating a giant sphenoethmoidal encephalocele containing eloquent brain. The cleft lip was also repaired at the same time. The ability to work through multiple corridors can enhance the safety and efficacy of an often-treacherous operative endeavor.

Anterior release without odontoidectomy for irreducible atlantoaxial dislocation: transoral or endoscopic transnasal?

To compare transoral and endoscopic transnasal anterior release without odontoidectomy and posterior reduction and fixation to treat irreducible atlantoaxial dislocation (IAAD). From June 2006 to January 2017, 35 consecutive patients with IAAD underwent transoral (Tr-Oral group) or endoscopic transnasal (Tr-Nasal group) release and posterior fixation and fusion in our department. Clinical neurological recovery (Japanese Orthopedic Association (JOA) score) and radiological reduction parameters including atlantodontoid interval (ADI), space available for the cord (SAC) and cervicomedullary angle (CMA) were analyzed and compared. The operation duration, blood loss, length of intensive care unit (ICU)/hospital stay and complications were recorded. All 35 patients (18 and 17 patients in the Tr-Oral and Tr-Nasal groups, respectively) were followed up for a mean of 36.4months (range, 21-60months). All patients achieved excellent anatomical reduction and clinical neurological recovery, with no significant differences between the two groups. The JOA score, ADI, SAC and CMA were not significantly different between the two groups at various postoperative points. Although the Tr-Oral group had shorter operation time and less blood loss than the Tr-Nasal group, the Tr-Nasal group tended to have a significantly shorter hospital/ICU stay, earlier extubation and earlier oral intake than the Tr-Oral group. The transoral and endoscopic transnasal approaches can achieve equivalent release and reduction effects when treating IAAD. Compared to the transoral approach, the endoscopic transnasal route is less invasive with earlier extubation and oral intake, shorter hospital/ICU stays and lower medical costs, which is conducive to enhancedrecoveryafter surgery.

A Lady with Systemic Lupus Erythematosus Complicated with Central Venous Sinus Thrombosis: A Case Report

Systemic lupus erythematosus (SLE) is associated with an increased risk of venous thromboses and cerebrovascular diseases. Herein, we discuss the case of a young 38-year-old Asian lady who was presented with cerebral venous sinus thrombosis (CVST) shortly after she was diagnosed with SLE. She developed headache, right hemiparesis and sustained an episode of seizure on the first presentation. CVST was diagnosed with plain computed tomography (CT) of the brain and CT venogram. With prompt administration of anticoagulation and immunosuppressant treatment for SLE, she had an excellent neurological recovery. There are many different risk factors for developing CVST in SLE patients. It has been reported in literature that CVST is usually associated with antiphospholipid antibodies but only around 40% of them would have positive antiphospholipid antibodies indicating that there are also other mechanisms contributing to the process [1]. As CVST in SLE is a rare condition, no standardized treatment strategy has been delineated. The main cornerstone of treatment would be anticoagulation and appropriate treatment for SLE as these patients are commonly associated with underlying active SLE. With timely management, the prognosis for CVST in SLE patients is generally favourable.

P1699 A case of atrial myxoma presenting with acute stroke

Abstract A 73-year-old female presented with sudden reduced level of consciousness on the background of rheumatoid arthritis and dyslipidaemia. On examination she had a Glascow Coma Score of 12 and an irregularly irregular pulse. The electrocardiograph confirmed atrial fibrillation and showed widespread T wave inversion. A computed tomography cerebral angiogram showed an acute basilar artery occlusion. She was transferred to a tertiary centre where she had successful endovascular clot retrieval. An urgent transthoracic echocardiogram (figure 1) showed apical hypertrophy, normal systolic function and a large right atrial mass. The left atrial size was normal. A transoesophageal echocardiogram (figure 3) confirmed a large pedunculated mobile mass with a hypermobile septum consistent with a patent foramen ovale. There was no right to left doppler flow, however the atrial mass obstructed the course, and a bubble study was positive. The cardiac magnetic resonance image (figure 2) showed a 47 x 48 mm pedunculated lesion within the right atrium, arising from the intraventricular septum, demonstrating moderate T2 signal intensity, and intermediate T1 signal intensity, with avid enhancement, consistent with a right atrial myxoma. There was increased apical wall thickening at 15mm which confirmed apical hypertrophic cardiomyopathy. An open surgical resection and left atrial appendage ligation was performed on day 11 of admission. Histopathology confirmed an atrial myxoma. She had an excellent neurological recovery with only mild diplopia. The mechanism of stroke was likely atrial fibrillation secondary to increased left atrial pressure from apical hypertrophic cardiomyopathy. However, the unexpected finding of a right atrial myxoma with a corresponding patent foramen ovale provides a second possible mechanism. Abstract P1699 Figure. Right atrial Myxoma

Functional outcome of cervical spine locking plate fixation in traumatic quadriplegics

Introduction: The cervical spine column is extremely vulnerable to injury due to its specific facet joint articulation. The most serious complication quadriplegia occurs in almost 40to50% of cases. Surgery is indicated if signs of instability, significant dislocation or neurological deficit are present. Over the last 15 years, the anterior approach has become the gold standard. Aim of Study: To evaluate the functional, clinical and radiographic results of traumatic cervical spine instability which were treated surgically using Cervical Spine Locking Plate (CSLP) fixation and anterior interbody fusion with tricortical iliac crest bone graft.Materials and Methods: This is a prospective and retrospective study 23 Patients who attended the Orthopaedics casualty Medical College Kozhikode, with traumatic quadriplegia due to lower cervical spine injury who were treated with anterior cervical locking plate during a period of 2 years from June 2010 onwards were studied. The outcome of the treatment was compared in terms of relief of symptoms, neurological recovery, clinical and radiological stability and improvement of rehabilitation. The cases were followed up for 2 years from the beginning of the treatment.Analysis and Results: The following observations were made from this study. The youngest patient in the study was 16 and the oldest 65 years. The most common level of injury in this study was C5-C6 (11 patients), Only 9 patients were treated within 72 hours. Neurological recovery was evaluated by preoperative and postoperative FRANKEL and ASIA scores. All patients were densely quadriplegic before surgery, 6 patients had no change in neurology and expired in postoperative period. Excellent neurological recovery was seen in only minimal number of patients. In the postoperative period, for functional outcome measurement, patients were evaluated using modified ODOMS criteria. Out of all the patients, 13 had good fusion status. Conclusion: The ideal management of traumatic cervical spine instability in lower cervical spine injury is anterior stabilization with cervical spine locking plate. The surgery related complications are relatively very less, and the survived patients had significant improvement in their neurological and functional status All the patients had good radiological fusion and no complications in union.

E-CPR as a bridge for decision in the cath lab

Aim: Refractory cardiogenic shock (CS) complicates 5–7% of cases with ST-elevation myocardial infarction (STEMI), and is a leading cause of hospital death after myocardial infarction.1 CS complicating acute myocardial infarction (AMI) continues to have a high mortality of 40–50% despite early revascularization and adjunctive therapies.2 Extracorporeal membrane oxygenation (ECMO) technology has advanced significantly and is readily available at the bedside. This is a viable option for short-term support in the setting of acute cardiac ischemia. According to the 2003 USA National Registry of cardiopulmonary resuscitation (CPR), in-hospital cardiac arrest has a poor prognosis with an overall survival to hospital discharge rate of 17% with conventional CPR.3 One of the most common causes of cardiac arrest is ventricular fibrillation (VF) secondary to ischemia, which carries an improved prognosis if successfully defibrillated, with the rate of survival to hospital discharge being 34%.3 In cases with refractory ischemic VF, definitive therapy with percutaneous coronary intervention (PCI) may not be possible without anoxic brain injury secondary to hemodynamic collapse. CPR was introduced in the 1960s as a lifesaving method in patients with cardiac arrest.3 To supplement CPR in select patients, ECMO is used successfully for witnessed in-hospital cardiac arrest.3 In the setting of an AMI, bridging to a revascularization procedure is important in improving neurological outcome and overall survival. We report the profile and the outcome of patients in refractory VF resistant to defibrillation on ECMO support. Subsequent to revascularization, the patient's cardiac rhythm converted back to sinus rhythm with a single defibrillation shock with excellent neurological recovery. Methods: Since January 2014, we have been reviewing patients who had suffered from progressive severe refractory CS post STEMI undergoing emergency PCI on percutaneous veno-arterial (VA)-ECMO support. Results: For 11 male patients (mean age 50 ± 18 years), the mean duration of support was 7 ± 4 days. Of these patients, 9 (81%) were weaned successfully from ECMO. However, two patients on ECMO support died: one due to massive gastrointestinal bleeding and the other due to septic shock. Three other patients also died; one due to occluded stent on third day post-ECMO removal, one due to intracranial hemorrhage on second day post-ECMO removal, and one due to septic shock on fourth day post-ECMO removal. The 30-day survival was 54% (6/11 patients) without any neurological deficit. Conclusion: VA-ECMO has shown to be an option to bridge patients in CS and/or refractory VF to allow for a successful revascularization procedure and ultimately good neurological and survival outcome.

Functional Outcome of Intradural Extramedullary Spinal Tumors after Surgical Resection

Intradural extramedullary (IDEM) spinal tumors account about 40% of all intraspinal tumors and mainly represented by nerve sheath tumors and meningiomas. These two tumors represent about 55% of IDEM tumors and other rare tumors are dermoid, epidermoid, lipomas, metastatic tumors, paragangliomas etc.Technical advances in imaging techniques, MRI and surgical procedures have brought about excellent clinical results of IDEM tumors after surgery in last two decades. However, a small percentage of patients still present poor postoperative neurological outcome due to delayed in diagnosis and surgical intervention, severity of preoperative neurological defi cits and adverse pathology.The aim of this study is to analyze and discuss about the surgical outcome of 65 IDEM tumors operated in twelve years’ period.This is a retrospective study of 65 patients who were operated for IDEM tumors, between 1999 and 2012 in Department of Neurosurgery. One patient who had IDEM arteriovenous malformation was excluded from the study.Neurological outcome was scaled by McCormick’s grading. Follow up period ranged for 5 years to 17 years.After the clinical evaluation, all the patients suspected of having spinal tumors were subjected for MRI with Gadolinium enhancement of presumed level of spine based on neurological findings. Total excision of all IDEM tumors was performed using operating microscope. No intraoperative neurophysiological monitoring was used.There were 40 male and 25 female and age ranged from 10 to 80 years. Most common IDEM tumors were nerve sheath tumors (44), meningiomas (13), hydatid cyst (2), dermoid/epidermoid (2), arachnoid cyst (2) and n were thoracic, cervical and lumbar spines.Total tumor excision was performed in all cases. Post operative Complications rate was 12.3% (7) and common complications included were CSF Leak (5), wound infection (2), meningitis (1).There was no surgery related mortality. Postoperatively 60 patients had improved neurological status, 5 patients had stable neurology. There was no postoperative neurological deterioration.On followed up period 2 patients showed features of recurrence of tumor in 5 years’ period and underwent resurgical treatment. Those two patients with recurrent tumors were nerve sheath tumors.Majority of IDEM tumors are benign and total cure is possible in almost all cases if tumor is excised totally. Excellent neurological recovery has been observed in more than 95% of cases.Nepal Journal of Neuroscience. Vol. 13, No. 2, 2016, Page: 73-80

Neurological Prognostication of Cardiac Arrest in an Era of Extracorporeal Membrane Oxygenation.

A neuron-specific enolase level greater than 33 ng/mL at days 1 to 3 or status myoclonus within 1 day are traditional indicators of poor neurological prognosis in survivors of cardiac arrest. We report the case of a 70-year-old man who received extracorporeal membrane oxygenation following cardiac arrest. Despite having both an elevated neuron-specific enolase concentration of 68 ng/mL and status myoclonus, he made an excellent neurological recovery. The value of traditional markers of poor prognosis such as elevated neuron-specific enolase or status myoclonus has not been systematically validated in patients treated with extracorporeal membrane oxygenation or therapeutic hypothermia. Straightforward application of practice guidelines in these cases may result in tragic outcomes. This case underscores the need for reliable prognostic markers that account for recent advances in cardiopulmonary and neurological therapies.