Full Neurological Recovery Research Articles

Outcomes of the resuscitative and emergency thoracotomy at a Dutch level-one trauma center: are there predictive factors for survival?

PurposeTo investigate the 30-day survival rate of resuscitative and emergency thoracotomies in trauma patients. Moreover, factors that positively influence 30-day survival rates were investigated.MethodsA retrospective study of patients (> 16 years), between 2008 and 2020, who underwent a resuscitative or emergency thoracotomy at a level-one trauma center in the Netherlands was conducted.ResultsFifty-six patients underwent a resuscitative (n = 45, 80%) or emergency (n = 11, 20%) thoracotomy. The overall 30-day survival rate was 32% (n = 18), which was 23% after blunt trauma and 72% after penetrating trauma, and which was 18% for the resuscitative thoracotomy and 91% for the emergency thoracotomy. The patients who survived had full neurologic recovery. Factors associated with survival were penetrating trauma (p < 0.001), (any) sign of life (SOL) upon presentation to the hospital (p = 0.005), Glasgow Coma Scale (GCS) of 15 (p < 0.001) and a thoracotomy in the operating room (OR) (p = 0.018). Every resuscitative thoracotomy after blunt trauma and pulseless electrical activity (PEA) or asystole in the pre-hospital phase was futile (0 survivors out of 11 patients), of those patients seven (64%) had concomitant severe neuro-trauma.ConclusionThis study found a 30-day survival rate of 32% for resuscitative and emergency thoracotomies, all with good neurological recovery. Factors associated with survival were related to the trauma mechanism, the thoracotomy indication and response to resuscitation prior to thoracotomy (for instance, if resuscitation enables enough time for safe transport to the operating room, survival chances increase). Resuscitative thoracotomies after blunt trauma in combination with loss of SOL before arrival at the emergency room were in all cases futile, interestingly in nearly all cases due to concomitant neuro-trauma.

AN INTERESTING CASE OF CARDIAC ARREST DURING THE CREATION OF AV FISTULA

TYPE: Case Report TOPIC: Cardiovascular Disease INTRODUCTION: We present an intersting case of cardiac arrest due to hemodynamic compromise occurring soon after AV fistula creation. CASE PRESENTATION: 45-year-old woman with medical history of ESRD on hemodialysis and pulmonary hypertension presented for left-arm AV fistula creation. Initial parts of the procedure went uneventful. However, towards the end of procedure, 10 minutes after unclamping of the graft, patient became hypotensive and suffered from cardiac arrest secondary to pulseless ventricular tachycardia progressing to torsades. Patient received CPR and multiple defibrillator shocks, epinephrine, IV magnesium sulfate and amiodarone boluses. Blood gas showed pH of 7.05 and lactate 6.5 mmol/L. Potassium, magnesium and phosphate levels were normal. She was started on epinephrine drip for hemodynamic support and heparin drip due to concern of PE. STAT TTE showed severe LVH with LVEF of 55 to 60%, moderate pulmonary hypertension, normal RV size and function. CTA of chest did not show any evidence of pulmonary embolism therefore heparin was stopped. Patient was transferred to ICU where she remained stable and had a full neurologic recovery. DISCUSSION: AV fistula creation in patients with pre-existing pulmonary hypertension and RV dysfunction could result in increased venous return and RV preload leading to acute RV dilatation. This could cause septal shift towards the left resulting in decreased LV preload, leading to decreased cardiac output, potentially resulting in hypotension. Decreased coronary and systemic perfusion could also result in myocardial ischemia and RV failure leading to arrhythmias and death. CONCLUSIONS: Physicians should be aware of this potentially fatal acute complication of AV fistula creation. DISCLOSURE: Nothing to declare. KEYWORD: Cardiac Arrest, AV Fistula, hemodynamic effects, dialysis access, high output cardiac failure

Prehospital interventions and neurological outcomes in marathon-related sudden cardiac arrest using a rapid mobile automated external defibrillator system in Japan: a prospective observational study

ObjectiveTo describe neurological outcomes after sudden cardiac arrests (SCAs) in road and long-distance races using a rapid mobile automated external defibrillator system (RMAEDS) intervention.MethodsA total of 42 SCAs from 3...

Transcranial magnetic stimulation tractography and the facilitation of gross total resection in a patient with a motor eloquent glioblastoma: illustrative case.

BACKGROUNDIn patients with perieloquent tumors, neurosurgeons must use a variety of techniques to maximize survival while minimizing postoperative neurological morbidity. Recent publications have shown that conventional anatomical features may not always predict postoperative deficits. Additionally, scientific conceptualizations of complex brain function have shifted toward more dynamic, neuroplastic theories instead of traditional static, localizationist models. Functional imaging techniques have emerged as potential tools to incorporate these advances into modern neurosurgical care. In this case report, we describe our observations using preoperative transcranial magnetic stimulation data combined with tractography to guide a nontraditional surgical approach in a patient with a motor eloquent glioblastoma.OBSERVATIONSThe authors detail the use of preoperative functional and structural imaging to perform a gross total resection despite tumor infiltration of conventionally eloquent anatomical structures. The authors resected the precentral gyrus, specifically the paracentral lobule, localized using intraoperative mapping techniques. The patient demonstrated mild transient postoperative weakness and made a full neurological recovery by discharge 1 week later.LESSONSPreoperative functional and structural imaging has potential to not only optimize patient selection and surgical planning, but also facilitate important intraoperative decisions. Innovative preoperative imaging techniques should be optimized and used to identify safely resectable structures.

Extracorporeal membrane oxygenation in children: An update of a single tertiary center 11-Year experience from Croatia.

Extracorporeal membrane oxygenation (ECMO) is an important treatment option for organ support in respiratory insufficiency, cardiac failure, or as an advanced tool for cardiopulmonary resuscitation. Reports on pediatric ECMO use in our region are lacking. This study is a retrospective review of all pediatric cases that underwent a veno-arterial (VA) or veno-venous (VV) ECMO protocol between November 2009 and August 2020 at the Department of Pediatrics, University Hospital Center Zagreb, Croatia. Fifty-two ECMO runs identified over the period; data were complete for 45 cases, of which 23 (51%) were female, and median age was 8 months. Thirty-eight (84%) patients were treated using the VA-and 7 (16%) using VV-ECMO. The overall survival rate was 51%. Circulatory failure was the most common indication for ECMO (N = 38, 84%), and in 17 patients ECMO was started after cardiopulmonary resuscitation (E-CPR). Among survivors, 74% had no or minor neurological sequelae. Variables associated with poor outcome were renal failure with renal replacement therapy (p < .001) and intracranial injury (p < .001). Overall survival rate in our cohort is comparable to the data published in the literature. The use of hemodialysis was shown to be associated with higher mortality. High rates of full neurological recovery among survivors are a strong case for further ECMO program development in our institution.

When Agitation, Hallucination, and Paranoia Mean More Than Psychosis.

When Agitation, Hallucination, and Paranoia Mean More Than Psychosis.

A case series for Enneking Stage III vertebral hemangiomas management, outcome, and literature review

Objectives: Vertebral hemangiomas are benign, slow-growing tumors. They represent 2–3% of spinal tumors and are incidentally found. Various treatment protocols have been described for Enneking Stage III vertebral hemangiomas. However, a comprehensive treatment protocol is still lacking. This case series aimed to describe the management of Enneking Stage III vertebral hemangiomas in two centers. Methods: This case series was performed by retrospectively reviewing the medical records of all patients diagnosed with Enneking Stage III vertebral hemangiomas at two centers in Riyadh, Saudi Arabia, from 2010 to 2020. Results: Eleven patients had Enneking Stage III vertebral hemangiomas. Mean follow-up was 47.5 ± 24.1 (range 9–120) months. All patients were symptomatic; the most common presentations were neurological deficits with or without myelopathy (n = 6). Ten patients underwent surgical decompression with instrumentation. One patient refused surgery and underwent vertebroplasty and repeated sclerotherapy. All patients regained full neurological recovery during their follow-ups with a mean duration of 49.4 (range, 14–120) months. No recurrence was reported. Conclusion: In all 11 patients, they showed full recovery and clinical improvement regardless of treatment variety. Therefore, a larger study comparing various treatment methods is needed to reach a gold standard approach.

The Power of Patient Stories to Inspire Us to Prevent Cardiovascular Disease and Death: Personal Reflections on the AHA's Scientific Sessions 2021.

The Power of Patient Stories to Inspire Us to Prevent Cardiovascular Disease and Death: Personal Reflections on the AHA's Scientific Sessions 2021.

Posterior Reversible Encephalopathy Syndrome in a Child with Sickle Cell Disease and SARS-CoV-2 Infection

AbstractThe full range of neurological manifestations of novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) infection in children remains incompletely characterized. Here, we discussed a 7-year-old male child patient with sickle cell disease (SCD), who presented with acute encephalopathy and nonconvulsive (electrographic only) seizures immediately prior to the onset of severe symptomatic SARS-CoV-2 infection, manifesting as respiratory failure, systemic inflammatory response, and hypertension. Brain imaging confirmed hyperintense lesions consistent with posterior reversible encephalopathy syndrome (PRES). Following aggressive symptomatic management including antiseizure medication, immunomodulatory treatment of SARS-CoV-2 infection, and intensive blood pressure control, he made a full neurological recovery. PRES has been observed in adults with SARS-CoV-2 infection, but there are few published reports of this neurological manifestation in children. Our case demonstrates that PRES should be a consideration in children with SARS-CoV-2 infection presenting with acute neurological decompensation, especially in the setting of preexisting risk factors for cerebrovascular dysregulation such as SCD.

Surgical Treatment of the Intraspinal Rib Head Dislocation in Children With Dystrophic Scoliosis Secondary to Type 1 Neurofibromatosis.

Background:The purpose of this study was to explore the surgical treatment of intraspinal rib head dislocation (IRH) in children with dystrophic scoliosis secondary to type 1 neurofibromatosis (NF1-DS).Methods:From 2006 to 2019, 32 of 128 patients with NF1-DS were found to have IRH and enrolled in this study. There were 19 boys and 13 girls with an average age of 8.8±2.6 years. Patients were divided into 2 groups: group A (n=25) without IRH resection and group B (n=7) with IRH resection. The intraspinal rib proportion (IRP), apical vertebra rotation, apical vertebral translation, main thoracic curve Cobb angle, trunk shift and thoracic kyphosis, lumbar lordosis, and sagittal vertebral axis were measured before and after the operation. Spinal injury was graded based on the American Spinal Injury Association (ASIA) Impairment Scale.Results:The study group had a total of 42 IRH. The mean follow-up duration was 46.1±28.7 months. The preoperative IRP in both groups was similar (35.5±14.3% vs. 31.2±15.3%, P=0.522). The postoperative IRP was lower in group B (18.5±11.2% vs. 0%, P=0.002). The IRP in group A decreased from preoperative (31.2±15.3%) to postoperative (18.5±11.2%) (P<0.05). There was no significant difference in the apical vertebra rotation, apical vertebral translation, main thoracic curve Cobb angle, trunk shift, thoracic kyphosis, lumbar lordosis, and sagittal vertebral axis between the 2 groups before surgery and after surgery. Four patients with nerve injury caused by the IRH had full neurological recovery postoperatively. All patients were ASIA grade E at the last follow-up.Conclusions:The surgical treatment of IRH in children with NF1-DS should be determined on the basis of the presence of preoperative neurological symptoms. This study supports the practice of correcting spinal deformities only in patients with mild or no spinal cord injury. If there are obvious neurological symptoms, IRH resection is necessary to relieve spinal cord compression to recover nerve function.Level of Evidence:Level III.

Skip hemilaminectomy for the treatment of holospinal epidural abscess: A single-center experience.

Background: Holospinal epidural abscesses (HEAs) are rare with potentially devastating consequences. Urgent bony decompression and abscess evacuation with long-term antibiotic therapy are typically the treatment of choice.Methods: We reviewed cases of holospinal HEAs operated on between 2009 and 2018. Variables studied included preoperative laboratories, CT/MR studies plus clinical and radiographic follow-up for between 34 and 60 postoperative months.Results: We utilized skip hemilaminectomies to minimize the risks of segmental instability. Targeted antibiotic therapy was also started immediately and maintained for 6 postoperative weeks. MR/CT studies documented full radiographic and neurological recovery between 6 and 12-months later.Conclusion: HEAs may be treated utilizing multilevel skip hemilaminectomies to help maintain spinal stability while offering adequate abscess decompression/resolution.

Stridor Due to Cranial Nerve X Palsy Progressing to Polyneuropathy in a Teenager With COVID-19

The neurologic manifestations of coronavirus disease 2019 (COVID-19) are wide-ranging, including various cranial neuropathies, beyond anosmia and dysgeusia, the exact neuropathological mechanism of which are yet unknown. Acute cranial nerve (CN) X neuritis with vocal cord paralysis has not been reported in COVID-19 and is a rare presentation of neuropathy in general. A girl aged 14 years was admitted with stridor. She was diagnosed with symptomatic COVID-19 8 days before. By presentation, fever had resolved, but she had developed stridor; sore throat with dysphagia; chest, shoulder, and back pain; and generalized weakness. Neurologic examination and laryngoscopy were consistent with isolated left CN X palsy. Steroids were started, but neurologic disease progressed with subjective pain, right lower face numbness, and eye fatigability. Respiratory distress increased, and she was intubated for airway protection. MRI revealed abnormal enhancement of CNs III, V, XII, and X. Cerebrospinal fluid studies were normal. Nasopharyngeal severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test result was positive. She was treated with intravenous immunoglobulin, a total of 2 g/kg, and steroids were continued. She made a full neurologic recovery and was discharged after 9 days of hospitalization. This is a case of a teenager who presented with an acute, life-threatening CN X palsy and development of a progressive polyneuropathy in the setting of COVID-19. Although there was concern for Guillain-Barre syndrome, a definitive diagnosis could not be made, and the unusual features of this case, including presentation with stridor and predominate CN involvement seem to indicate a separate symptomatic COVID-19–associated polyneuritis.

Surgical Intervention for Enneking Stage-III Vertebral Hemangiomas and Literature Review

Introduction: Vertebral hemangiomas are benign, slow-growing tumors. They represent 2–3% of spinal tumors and are incidentally found. Various treatment protocols have been described for Enneking stage-III vertebral hemangiomas. However, it is still controversial and a comprehensive treatment protocol is still lacking.&#x0D; Methodology: A retrospective clinical review was conducted on patients diagnosed with Enneking stage-III vertebral hemangiomas at two centers in Riyadh, Saudi Arabia between 2010 and 2020.&#x0D; Result: A total of 11 patients with Enneking stage-III vertebral hemangiomas were included. The mean follow-up period was 47.5 ± 24.1 (9–120 months) months. All patients were symptomatic; the most common presentations were neurological deficit and/or myelopathy (n = 7). Ten patients underwent surgical intervention. Six patients had preoperative embolization, with a mean blood loss of 880.00 ± 334.46 ml. One patient refused surgery and underwent vertebroplasty and repeated sclerotherapy. All patients regained full neurological recovery during follow-up. No recurrence was reported.&#x0D; Conclusion: Intralesional spondylectomy showed good results in treating Enneking Stage-III vertebral hemangiomas. However, larger studies comparing treatment methods are needed to reach a gold standard approach.

Blinatumomab Associated Seizure Risk in Patients with Down Syndrome and B-Lymphoblastic Leukemia: An Interim Report from Children's Oncology Group (COG) Study AALL1731

INTRODUCTIONChildren with Down Syndrome (DS) and B-lymphoblastic leukemia (B-ALL) are at an increased risk of both relapse and treatment-related mortality, compared to those without DS. On COG study AALL1731 for de novo B-ALL, patients with DS and higher risk features (DS-High) are non-randomly treated with a regimen replacing intensive elements of conventional chemotherapy with three 28-day cycles of blinatumomab, with the combined goals of reducing toxicity and enhancing anti-leukemic efficacy. The DS-High group includes all NCI high risk (HR) patients; NCI standard risk (SR) patients with end-induction minimal residual disease positivity (>0.01%), unfavorable cytogenetics, CNS3 status, steroid pre-treatment, neutral cytogenetics with CNS2 status, or testicular disease. Neurotoxicity is a known risk of blinatumomab, with an incidence of 4% in block 1 and 1% in block 2 among pediatric patients with relapsed ALL (Brown et al, JAMA 2021). However, the specific risk in patients with DS has not been described to date. Here, we provide an early report of increased seizure incidence associated with blinatumomab in older DS-High patients enrolled on AALL1731 to date.METHODSWe reviewed seizure incidence among patients with DS enrolled on AALL1731 from June 2019 to June 2021 who had proceeded to receive blinatumomab. Blinatumomab was administered at a dose of 15 mcg/m 2/day, using dexamethasone pre-medication in cycle 1. Infusions were interrupted for seizures, with resumption at 5 mcg/m 2/d permitted following full resolution for grade 1-3 seizures.RESULTSAmong DS NCI HR patients, 8 of 47 (17%) had a seizure during blinatumomab infusion (Table 1). All 8 seizures occurred in patients over 10 years old. Six of the 8 seizures occurred in the first cycle of blinatumomab, most in the first 3 days of the infusion. Four had concomitant fever or cytokine release syndrome. Seizures were grade 2 (n=2) or grade 3 (n=6), and all resolved with full neurologic recovery. Of the 8 patients, 5 elected to resume blinatumomab; no further seizures occurred in these patients. There was no indication of increased seizure risk among NCI SR DS-High patients (1 seizure among 11 patients), or among DS or non-DS patients receiving blinatumomab on other study strata (0 of 7 DS SR-Avg; 1 of 146 non-DS SR-Avg; and 2 of 120 non-DS SR-High).CONCLUSIONSThe incidence of seizures associated with blinatumomab in DS-ALL patients older than 10 years appears higher than previously reported in children without DS. The majority of seizures occurred within the first 3 days, all fully resolved with no sequelae, and no patient who resumed blinatumomab infusion at a lower rate experienced further seizures. Seizure prophylaxis may be advisable in DS patients while receiving blinatumomab, particularly those >10 years of age. Further follow-up and a larger sample size are needed to confirm incidence and identify risk factors predisposing DS patients to neurologic toxicity. [Display omitted] DisclosuresLi: Novartis Canada: Membership on an entity's Board of Directors or advisory committees. Raetz: Pfizer: Research Funding; Celgene: Other: DSMB member. Loh: MediSix therapeutics: Membership on an entity's Board of Directors or advisory committees. Gupta: Jazz Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees. Rau: Jazz Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Advisory Board; AbbVie Pharmaceuticals: Other: Spouse is employee and stock holder; Servier Pharmaceuticals: Consultancy. OffLabel Disclosure:This trial includes the use of blinatumomab in combination with chemotherapy for treatment of de novo B-lymphoblastic leukemia.

Ischaemic stroke caused by spontaneous unilateral carotid artery dissection in patient with connective tissue disorder

Background: Spontaneous cervical artery dissection is a major cause of ischaemic stroke in young patients. It is supposed that genetic variants associated with connective tissue disorders often lead to neurovascular complications, the management of which remains a challenge. Case presentation: A 30-year-old female was admitted to the Department of Neurology with an episode of visual disturbances, speech problems, and concomitant headache. Computed tomography angiography revealed left internal carotid artery dissection. Magnetic resonance of the brain showed cortical and subcortical acute ischaemic lesions in the left cerebral hemisphere. The patient was diagnosed with vascular Ehlers–Danlos syndrome based on the clinical course of the disease. Conservative treatment was administered with full neurological recovery. Conclusion: It is very important for clinicians to consider the coexistence of genetically determined connective tissue disorders in young patients who develop arterial dissections.

Cranial Neuropathies in Advanced Nasopharyngeal Carcinoma: Neurological Recovery and Prognosis After Modern Radiotherapy and Systemic Chemotherapy

Cranial neuropathy is a common presenting symptom of advanced T4 nasopharyngeal carcinoma (NPC). Data on neurological outcomes after modern intensity-modulated radiotherapy (IMRT) and chemotherapy are scarce. This study sets to evaluate the prognostic factors and recovery pattern of cranial neuropathies, using longitudinal clinical data from two tertiary oncology centers in endemic areas.Case records of consecutive T4 NPC patients who received definitive IMRT in 2004-2019 were reviewed. Distribution of cranial neuropathies at disease presentation were recorded. Time to partial and full neurological recovery, time from neurological recovery to re-palsy, relapse-free survival (RFS) and overall survival (OS) were estimated by the Kaplan-Meier method. Predictors for neurological recovery were analyzed using multivariable Cox regression.During the study period, 257 T4 NPC patients presented with 504 individual cranial neuropathies. The median time from neuropathy onset to NPC diagnosis was 2 months (IQR, 1-4 months). All patients completed definitive IMRT, and 94% of patients received chemotherapy. The 5-year RFS and OS of the combined cohort were 50.8% and 60.1% respectively. Median RFS of patients with single versus multiple neuropathies were 5.8 years and 4.2 years (P = 0.62). Cranial nerves (CN) VI (56.4%), V2 (47.9%) and V3 (29.2%) were most frequently involved. Over a median follow-up of 6.4 years, 111 (22%) and 289 (57.3%) neuropathies attained partial and full recovery respectively, and 86% of the recoveries occurred within the first year after definitive radiotherapy. CN III, IV, VI had the highest 5-year full recovery rate (72.7%), followed by CN V1-3 (60.3%), CN XII (48.6%), and CN II (18.2%) (P < 0.001). Positive smoking history, optic nerve involvement, and long duration of neuropathy were independent negative predictors for neurological recovery. After full recovery, re-palsy was observed in 6.9% (20/289) of the nerves, 60% of which co-occurred with local NPC recurrences at the base of skull.Rate and durability of cranial neuropathy recovery in this contemporary NPC cohort compared favorably with data from the 2D radiotherapy era. Both patient and disease factors affected the chance of nerve recovery. Re-palsy of recovered nerves should prompt careful evaluation for local recurrence.

THROMBECTOMY FOR ACUTE EMBOLIC STROKE FOLLOWING HEART SURGERY

Introduction Acute ischaemic stroke occurs in approximately 1-10% of patients undergoing cardiac surgery and can markedly impair recovery (1). Thrombolysis carries an unacceptably high risk of haemorrhage in the early postoperative period after heart surgery. Mechanical thrombectomy is becoming an increasingly preferred alternative to treat ischaemic strokes, and unlike thrombolysis, is not contraindicated in the early postoperative period. We report a patient who had witnessed onset of ischaemic stroke in the early postoperative period after aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) surgery and was treated with mechanical thrombectomy. Discussion An 81-year-old male patient underwent elective tissue AVR and CABG (internal mammary to left anterior descending coronary artery) surgery. Surgery was uncomplicated and following weaning from mechanical ventilation, the patient's trachea was extubated on the evening of surgery. His recovery progressed uneventfully and on the day after surgery, he was moved to a high dependency unit. On the morning of the second post-operative day, the patient had a witnessed rapid deterioration in conscious level, becoming unresponsive with a divergent gaze. Urgent plain CT scan of the brain showed hyperattenuation of the left middle cerebral artery (MCA) territory consistent with acute thrombosis. The patient was granted emergency funding for a mechanical thrombectomy and was transported to the regional neurology hospital. A mechanical thrombectomy was performed successfully, with digital subtraction angiography (DSA) confirming complete occlusion of the left MCA with poor collateral cross flow. The patient failed to recover neurological function and died approximately 24 hours later. Mechanical thrombectomy is now a well-established treatment for acute ischaemic stroke. There are clear advantages with regard to functional outcome for patients undergoing mechanical thrombectomy versus best available medical therapies such as thrombolysis (2). A recent systematic review of acute ischaemic stroke post cardiac surgery showed that 50% of patients who underwent endovascular mechanical thrombectomy had a full or good neurological recovery, 36% had moderate recovery and 14% had little improvement (1). Factors that may have led to a poor outcome in this patient's case included the delay in hospital transfer, the poor cerebral cross blood flow noted on DSA and extensive comorbidities. In conclusion, although there are many reports of mechanical thrombectomy being associated with a good neurological outcome from acute ischaemic stroke associated with cardiac surgery, outcome may not be improved if there is underlying cerebrovascular disease and intervention is delayed.

Critically ill patients with severe immune checkpoint inhibitor related neurotoxicity: A multi-center case series.

Serious immune checkpoint inhibitor (ICI)-related neurotoxicity is rare. There is limited data on the specifics of care and outcomes of patients with severe neurological immune related adverse events (NirAEs) admitted to the Intensive Care Unit (ICU). Retrospective study of patients with severe NirAEs admitted to the ICU at 3 academic centers between January 2016 and December 2018. Clinical data collected included ICI exposure, type of NirAE (central [CNS] or peripheral nervous system [PNS) disorders), and patient outcomes including neurological recovery and mortality. Seventeen patients developed severe NirAEs. Eight patients presented with PNS disorders; 6 with myasthenia gravis (MG), 1 had a combination of MG and polyneuropathy and 1 had Guillain-Barre syndrome. Nine patients had CNS disorders (6 seizures and 5 had concomitant encephalopathy. During ICU admission, 65% of patients required mechanical ventilation, 35% vasopressors, and 18% renal replacement therapy. The median ICU and hospital length of stay were 7 (2-36) and 18 (4-80) days, respectively. Hospital mortality was 29%. At hospital discharge, 18% of patients made a full neurologic recovery, 41% partial recovery, and 12% did not recover. Severe NirAEs while uncommon, can be serious or even life-threatening if not diagnosed and treated early.

Extreme hyponatraemia due to primary polydipsia and quetiapine-induced SIAD.

SummaryHyponatraemia is the most common electrolyte disturbance in hospitalised patients and is associated with numerous adverse outcomes. Patients with schizophrenia are particularly susceptible to hyponatraemia, in part due to the close association between this condition and primary polydipsia. We report the case of a 57-year-old woman with schizophrenia and primary polydipsia who was receiving inpatient psychiatric care. She became increasingly confused, had multiple episodes of vomiting, and collapsed 1 week after being commenced on quetiapine 300 mg. On examination, she was hypertensive and her Glasgow coma scale was nine. She had a fixed gaze palsy and a rigid, flexed posture. Investigations revealed extreme hyponatraemia with a serum sodium of 97 mmol/L. A CT brain demonstrated diffused cerebral oedema with sulcal and ventricular effacement. A urine sodium and serum osmolality were consistent with SIAD, which was stimulated by the introduction of quetiapine. The antidiuretic effect of vasopressin limited the kidney’s ability to excrete free water in response to the patients' excessive water intake, resulting in extreme, dilutional hyponatraemia. The patient was treated with two 100 mL boluses of hypertonic 3% saline but deteriorated further and required intubation. She had a complicated ICU course but went on to make a full neurological recovery. This is one of the lowest sodium levels attributed to primary polydipsia or second-generation antipsychotics reported in the literature.Learning pointsThe combination of primary polydipsia and SIAD can lead to a life-threatening, extreme hyponatraemia.SIAD is an uncommon side effect of second-generation anti-psychotics.Serum sodium should be monitored in patients with primary polydipsia when commencing or adjusting psychotropic medications.Symptomatic hyponatraemia is a medical emergency that requires treatment with boluses of hypertonic 3% saline.A serum sodium of less than 105 mmol/L is associated with an increased risk of osmotic demyelination syndrome, therefore the correction should not exceed 8 mmol/L over 24 h.

Thoracic intramedullary neurosarcoidosis with thoracic disc herniation: Diagnostic importance of intramedullary contrast enhancement

Background: Thoracic intramedullary neurosarcoidosis is an uncommon but serious manifestation of spinal cord disease. Its concomitant occurrence with thoracic disc herniation can mislead the physician into attributing neurologic and radiographic findings in the spinal cord to disc pathology rather than inflammatory disorder. Here, we present such a rare case of concomitant thoracic disc and spinal neurosarcoidosis.Case Description: A 37-year-old male presented with progressive right lower extremity weakness and numbness. Magnetic resonance imaging (MRI) of the thoracic spinal cord revealed a T6-T7 paracentral disc eccentric to the right with T2 signal change extending from T2 to T10 level. This prompted acquiring a contrasted MRI that also depicted intramedullary enhancement around the T6-T7 disc bulge. Computed tomography scan of the chest showed mediastinal lymphadenopathy concerning for sarcoidosis. Lymph node biopsy confirmed the diagnosis of sarcoidosis, and high-dose steroid treatment was initiated. The patient had significant symptomatic improvement with steroids with full neurological recovery and improvement of his symptoms.Conclusion: While stenosis from thoracic disc disease could potentially suggest a mechanical etiology for the patient’s symptoms, attention must be paid to the imaging findings as well as the degree and extent of cord signal change and intramedullary contrast enhancement. Appropriate and timely diagnosis is essential to avoid unnecessary invasive procedures.