History Of Neurological Symptoms Research Articles

Steroid-Induced Progressive Multifocal Leukoencephalopathy (PML) in HIV Patient: A Paradoxical Effect

Introduction: Progressive multifocal leukoencephalopathy (PML) is a rare, severe demyelinating disease of the central nervous system predominantly found in patients with acquired human immunodeficiency syndrome (AIDS). Case Presentation: This report details a case involving a male HIV-positive patient with PML who discontinued his highly active antiretroviral therapy (HAART) treatment 10 days after being diagnosed with HIV. The patient had no history of neurological symptoms either before or after his HIV diagnosis until he was administered corticosteroids. Notably, he began experiencing ataxia shortly after starting dexamethasone. Progressive multifocal leukoencephalopathy was diagnosed through polymerase chain reaction (PCR) testing for the John Cunningham virus (JCV) in the cerebrospinal fluid (CSF). The PML lesions were confined to the cerebellum. Conclusions: The occurrence of neurological symptoms (activation of JCV) after administering corticosteroids to a patient with HIV-who had not received any antiretroviral treatment for 4 years-raises a critical question: Is the use of corticosteroids, which are a primary treatment for immune reconstitution inflammatory syndrome (IRIS), a double-edged sword in CNS-IRIS?

Neurologic manifestations in hospitalized patients with COVID‐19

AbstractBackgroundTo investigate the effect of pre‐existing neurological symptoms and disease in coronavirus disease 2019 (COVID‐19) health outcomes in a large Illinois‐based cohort.MethodA multicenter retrospective study analyzed differences in a cohort of COVID‐19 positive patients with and without baseline neurological symptoms or disease admitted to RUSH University Systems for Health from March to November 2020. We measured sex and health outcome differences in hospitalization rates, symptoms during initial admission, complications, readmissions, and mortality of the two groups.ResultOf the total of 1708 hospitalized COVID‐19 positive patients (mean age: 58.04, 930 males) — 31% [527] patients had a history of neurological symptoms and/or disease, 9% [140] with dementia. Nonspecific symptoms during hospitalization including myalgia (19%), headache (11%), epilepsy (0.8%), tremors (3%), and abdominal pain (11%) were reported more frequently in patients with a neurologic history. Female patients with pre‐existing neurological conditions were hospitalized more than their male counterparts (40% versus 24%). Compared to those with no neurological conditions, patients with neurological conditions had higher rates of complications, such as acute myocardial infarction (13% vs. 8%; p = 0.002) and deep vein thrombosis/pulmonary embolism (14% vs. 10%; p = 0.02). Multivariate analysis showed that history of stroke and migraines are independently associated with readmission to a hospital floor (generalized linear model, z = 2.092, z = 3.320, p = 0.036, p < 0.001, respectively); of those readmitted, 13% had a history of dementia. Of the patients that died in hospital, 6% had a history of dementia.ConclusionNeurologic manifestations are common in hospitalized COVID‐19 positive patients and are associated with higher rates of complications during hospitalization. The increasing evidence for SARS CoV‐2’s impact on the central nervous system raises important questions on the long‐term consequences of this virus to patients with pre‐existing brain injury.

Unique Presentation of Bing-Neel Syndrome With Co-existing Chronic Lymphocytic Leukemia.

Unique Presentation of Bing-Neel Syndrome With Co-existing Chronic Lymphocytic Leukemia.

Low dose enzalutamide in metastatic castration-resistant prostate cancer: A retrospective Caribbean study.

e16548 Background: There is scarce information on the efficacy of low-dose enzalutamide in metastatic castration-resistant prostate cancer. We report on a series treated with half dose enzalutamide. Methods: We observed a trend in our practice to initiate low-dose enzalutamide at the time of disease progression in older patients considered frail, presenting with cardio-vascular comorbidity or with history of neurological symptoms. Records were retrospectively reviewed. The selection criteria were: 1) Metastatic disease demonstrated by at least one imaging modality, CT, bone scan, or positron emission tomography. 2) Progression of prostate specific antigen (PSA). 3) Castrate testosterone level ( < 0.2 ng/mL). 4) Enzalutamide treatment at 80 mg or less, once daily. To estimate the rate of PSA response, we used linear interpolation to compute the time from the initiation of low-dose enzalutamide to 50% PSA reduction. Results: Between November 2015 and December 2018 at the Martinique University Hospital, 10 patients matching the selection criteria were treated with ≤ 80 mg enzalutamide od: 8 started de novo with the low dose, 2 started with 160 mg but required dose reduction for intolerance. The mean age was 78 years (range 67-84). Three had painful bone metastases. The mean PSA at start of low dose enzalutamide was 88 ng/mL (range 1.06 - 251.8). All patients were maintained with reduced dose. At the current follow-up of 9 months (range 0 - 36 months), PSA response was observed in 7 patients ( = 70%), 1 was not evaluable (PSA not assessed), 2 did not respond. Of the 2 non-responders, one had no sign or symptom of disease progression; the other presented with extensive disease progression previously treated with abiraterone, he refused to receive increased dose enzalutamide. Among the 7 responders, the time to 50% PSA reduction was 57 days (range 26 - 119). Currently, the decline of PSA remains sustained in 6 of the 7 responders, it increased in 1 who discontinued enzalutamide. Pain decreased in the 3 symptomatic patients, including the PSA non-responder. Conclusions: Low dose enzalutamide appears efficient in a large proportion of selected frail patients. Further follow-up is required to evaluate the long-term response.

A tropomyosin-receptor kinase-fused gene mutation associates with vacuolar myopathy.

A 44-year-old Caucasian man presented with a 7-year history of upper and lower limb muscle fasciculations and cramps, progressive asymmetric weakness, muscle atrophy, and length-dependent sensory loss. His parents (deceased), 3 older siblings, and 3 children had no history of neurologic symptoms, including weakness and sensory symptoms, with the exception of cramps in the mother. He was not taking any medication known to cause neuropathy or myopathy. On examination, there was right greater than left shoulder girdle muscle weakness and atrophy (Medical Research Council grades 3/5 and 4/5), intrinsic left hand muscle weakness (4+/5) with atrophy, asymmetric pelvic girdle (4/5 right, 3/5 left), and left foot dorsiflexor weakness (4+/5). Strength of neck flexor and extensors, and axial muscles, was normal. He had bilateral calf muscle atrophy and weakness as suggested by his inability to stand on toes (figure, A–C). He was areflexic. Sensory examination revealed distal vibration and pinprick deficits in the upper and lower limbs in a length-dependent fashion. He had bilateral pes cavus. The authors thank the patient for the photographs; Dr. A. Kendler at University of Cincinnati for sharing the muscle biopsy slides; and Invitae for performing the additional analysis of genes associated with myopathies.

Evaluation of quality of life and fatigue in radiologically isolated syndrome

BackgroundRadiologically isolated syndrome (RIS) is a new subtype entity described at the very left of the demyelinating disease spectrum, where spatial dissemination of T2-weighted lesions can be documented on MRI in subjects with no history of neurological symptoms. ObjectivesThis study was a longitudinal assessment of health-related quality of life (HRQOL) and fatigue in RIS patients. MethodsNon-converted RIS patients were evaluated at the time of diagnosis, and at 1 and 2 years of follow-up; their scores were compared with scores in clinically isolated syndrome (CIS) patients and age-matched controls. ResultsSociodemographic characteristics were comparable at baseline. There was no statistical difference between RIS and CIS groups in terms of cerebrospinal fluid (CSF) positivity or T2 lesion load. For HRQOL evaluations, RIS patients scored the same as controls, while CIS patients scored lower. Fatigue was detectable in both RIS and CIS patients compared with baseline and with controls. Mental HRQOL scores decreased significantly for RIS patients during follow-up. ConclusionHRQOL impairment and fatigue were detectable during follow-up in both non-converted RIS and CIS patients.

Carotid Plaque Morphology Is Significantly Associated With Sex, Age, and History of Neurological Symptoms.

The purpose of this study was to analyze the association between morphological characteristics of human carotid plaques and patient's sex, age, and history of neurological symptoms. The study included 763 atherosclerotic plaques from patients treated surgically for carotid stenosis between 2004 and 2013. Histological analyses of carotid plaques were performed to assess the type of plaque (American Heart Association classification), the stability of the plaque, the extent of calcification, inflammation, and neovascularization, as well as the deposition of collagen and elastin. According to the scale of outcome measurement, logistic regression, ordinal regression, and multinomial regression analyses were applied. All results were adjusted for common risk factors of atherosclerosis. Male sex was associated with more cellularity (odds ratio [OR], 1.56; P=0.003), more inflammatory infiltrates (OR, 1.75; P<0.001), and more neovascularization (OR, 1.47; P=0.010), but less calcification (OR, 0.78; P=0.090). Symptomatic patients were more likely to have a lower amount of elastin (OR, 0.71; P=0.057). Higher age was associated with increased calcification (OR, 1.23; P=0.009). Unstable plaques were found more frequently in symptomatic patients (OR, 1.60; 95% confidence interval, 1.14-2.25; P=0.007). A multinomial regression model revealed that age, sex, and history of neurological symptoms were significantly associated with specific plaque types (P=0.009, P<0.001, and P=0.017, respectively). Plaque morphology differed between men and women and varied with age. Certain types of plaques (VI and VI/VII) as well as unstable plaques were significantly associated with a history of neurological symptoms. Thus, individual approaches (eg, in detection of plaque hemorrhage or thin fibrous caps) especially based on sex and age should be considered to identify patients at increased risk of stroke.

12. Co-existence of primary progressive MS and CMT1A

A 48-year old man presented with a 20-year history of neurological symptoms. He reported slowly progressive changes in gait, mild right leg weakness and subtle short-term memory problems. There was no history of discrete relapses and no family history of neurological disease. The neurological examination revealed upper and lower limb weakness, marked lower limb spasticity, globally brisk reflexes and extensor plantar responses. MRI of the brain demonstrated white matter T2/FLAIR hyperintensities with extensive pericallosal involvement and MRI of the spinal cord revealed lesions in the thoracic cord suggestive of demyelination. Somatosensory and visual evoked potentials were markedly delayed and oligoclonal bands were detected in cerebrospinal fluid, consistent with multiple sclerosis. Nerve conduction studies demonstrated electrophysiological evidence of a generalised demyelinating, sensorimotor neuropathy, without temporal dispersion or conduction block, suggestive of an inherited cause. Genetic testing revealed PMP22 duplication, confirming Charcot-Marie-Tooth disease type 1A. This case highlights the rare co-existence of acquired central demyelination (i.e. primary progressive MS) in conjunction with inherited peripheral demyelination (CMT 1A).

Changes in Vertebral Artery Blood Flow Following Various Head Positions and Cervical Spine Manipulation

ObjectiveThe objective of the study was to investigate the cerebrovascular hemodynamic response of cervical spine positions including rotation and cervical spine manipulation in vivo using magnetic resonance imaging technology on the vertebral artery (VA). MethodsThis pilot study was conducted as a blinded examiner cohort with 4 randomized clinical tasks. Ten healthy male participants aged 24 to 30 years (mean, 26.8 years) volunteered to participate in the study. None of the participants had a history of disabling neck, arm, or headache pain within the last 6 months. They did not have any current or history of neurologic symptoms. In a neutral head position, physiologic measures of VA blood flow and velocity at the C1-2 spinal level were obtained using phase-contrast magnetic resonance imaging after 3 different head positions and a chiropractic upper cervical spinal manipulation. A total of 30 flow-encoded phase-contrast images were collected over the cardiac cycle, in each of the 4 conditions, and were used to provide a blood flow profile for one complete cardiac cycle. Differences between flow (in milliliters per second) and velocity (in centimeters per second) variables were evaluated using repeated-measures analysis of variance. ResultsThe side-to-side difference between ipsilateral and contralateral VA velocities was not significant for either velocities (P = .14) or flows (P = .19) throughout the conditions. There were no other interactions or trends toward a difference for any of the other blood flow or velocity variables. ConclusionsThere were no significant changes in blood flow or velocity in the vertebral arteries of healthy young male adults after various head positions and cervical spine manipulations.

Prospective neurocognitive evaluation of patients undergoing carotid interventions

Distal cerebral embolization is a known complication of carotid interventions. We prospectively investigated whether subclinical microembolization seen on postoperative magnetic resonance imaging (MRI) leads to cognitive deficits in patients undergoing carotid revascularization procedures. Patients undergoing carotid interventions and eligible for MRI scanning were recruited. Among 247 patients who received preoperative and postoperative MRI evaluations, 51 also completed neuropsychologic testing before and at 1 month after their procedure. Cognitive evaluation included the Rey Auditory Verbal Learning Test (RAVLT) for memory evaluation and the Mini-Mental State Examination (MMSE) for general cognitive impairment screening. The 51 patients (all men), comprising 16 with carotid artery stenting (CAS) and 35 with carotid endarterectomy (CEA), were a mean age of 71 years (range, 54-89 years). Among them, 27 patients (53%) were symptomatic preoperatively, including 11 who had prior stroke and 16 who had prior preoperative transient ischemic attack symptoms. Most patients had significant medical comorbidities, including hypertension (96%), diabetes (31.3%), coronary artery disease (47%), and chronic obstructive pulmonary disease (15.7%). Two patients (4%) had prior ipsilateral CEA and eight had contralateral carotid occlusion (15.7%). Memory decline evident on RAVLT was identified in eight CAS patients and 13 CEA patients. Eleven patients had evidence of procedure-related microemboli. Although there was no significant difference in baseline cognitive function or memory change between the CEA and CAS cohorts, the CAS cohort had a significantly higher incidence of microembolic lesions. Multivariate regression analysis showed that procedure-related microembolization was associated with memory decline (P = .016) as evident by change in RAVLT. A history of neurologic symptoms was significantly associated with poor baseline cognitive function (MMSE; P = .03) and overall cognitive deterioration (change in MMSE; P = .026), as determined by Wilcoxon rank sum test and linear regression analysis, respectively. Although CEA and CAS are effective in stroke prevention, with minimal neurologic complication, neurocognitive effects remain uncertain. Procedure-associated microembolization and pre-existing neurologic symptoms are associated with poor baseline cognitive function and memory decline after the procedures. Further comprehensive cognitive evaluation to determine the benefit of carotid interventions is warranted.

Bladder dysfunction in peripheral neuropathies

Normal bladder function depends on the complex interaction of sensory and motor pathways. Bladder dysfunction can develop as a result of several neurological conditions. It can happen in a number of ways, including diabetic cystopathy, detrusor overactivity, bladder outlet obstruction, and urge and stress urinary incontinence. Diabetic neuropathy is the most common cause of peripheral neuropathy-associated bladder dysfunction. Guillain-Barré syndrome (GBS), human immunodeficiency virus (HIV)-associated neuropathy, chronic inflammatory demyelinating polyneuropathy (CIDP), and amyloid neuropathy are other major causes. The diagnosis of bladder dysfunction should be established by the history of neurological symptoms, neurological examination, and urological evaluation. Functional evaluation of the lower urinary tract includes cystometry, sphincter electromyography, uroflowmetry, and urethral pressure profilometry. Management of urinary symptoms in patients with bladder dysfunction is usually supportive. In some cases, alpha-blocker and/or anti-muscarinic agents are needed to help improve urinary dysfunction. Intermittent self-catheterization is needed occasionally for patients with slow and/or poor recovery.

Carotid Endarterectomy: Analysis of Early Complications (&lt;30 days) and Risk Factors for Postoperative New Brain Infarction

Purpose: We aimed to evaluate the early (＜30 days) results and to analyze risk factors for the development of stroke and new brain infarction (NBI) after carotid endarterectomy (CEA). Methods: From September 2003 to August 2008, 233 CEAs were performed on 222 patients with critical internal carotid artery (ICA) stenosis in a single center. Patient characteristics, history of neurological symptoms, procedural details, and postoperative complications were examined based on the medical records. The incidence and risk factors for early postoperative stroke were evaluated. After excluding CEAs without performing diffusion-weighted brain MRI, 128 CEAs were investigated for frequency and the risk factors of NBI were analyzed. Chi-square test, Fisher’s exact test, Student T-test, and logistic regression model were used for statistical analysis. Results: Of a total of 233 CEAs, any and ipsilateral stroke rates were 1.3% and 0.4%, respectively. There was no early postoperative mortality. Early postoperative complications included 4.3% in transient cranial nerve injury, 1.7% in myocardial infarction, and 3.4% in hematoma. In univariate analysis, the significant risk factor for stroke was plaque ulceration (P=0.04). The frequency of NBI and ipsilateral NBI were 8.4% and 3.1%, respectively. The ulceration on ipsilateral ICA revealed statistically significant risk factors for the development of NBI (RR, 5.29; 95% CI, 1.024∼27.325; P=0.04). Conclusion: Our study showed a lower incidence of stroke and NBI after carotid endarterectomy and that it is safe procedure for the treatment of patients with severe (＞70%) carotid stenosis. We also found that plaque with ulceration was a significant risk factor for the development of postoperative NBI.

CrossRef Listing of Deleted DOIs

Athletes that participate in contact and collision sports assume risk of serious injury each time they take the field. For those athletes that have sustained an episode of transient quadriplegia, the decision of whether to return to competition can be a difficult one. Some athletes, realizing how close they may have come to permanent injury, may decide that further participation is not in their best interest. Others may be somewhat undecided, and some may want to return at all costs. As the treating physician, the goal is to identify those athletes who after a single episode of transient quadriplegia are at increased risk for further injury and consequently should discontinue participation in contact sports. Factors that may contribute to that determination include mechanism of injury, prior history of neurologic symptoms or injury, and anatomic features that may predispose to further injury such as disc herniation, fracture, or cervical stenosis.

ヒトにおける前庭―視覚矛盾刺激により得られる前庭動眼反射（ＶＯＲ）適応現象の角速度特異性について

Vestibulo-ocular reflex (VOR) makes images remain relatively stable on the retina. To keep appropriate performance and minimize image slip throughout life, VOR is subject to long-term adaptive regulation by visual input. It has been reported that adaptive changes in VOR gain (eye velocity/head velocity) are evoked either by fitting subjects with magnifying, miniaturizing, or reversing spectacles during normal behavior or by moving a large visual field in or out of phase relative to the subject's head movement. These feature frequency-selectivity. We studied the flexibility of adaptive gain change in VOR required by a horizontal visual-vestibular mismatch in earth vertical axis rotation (EVAR), including adaptive gain change from EVA to off-vertical axis rotation (OVAR) and other velocities. The visual-vestibular mismatch was made by oscillating subjects in EVAR for 30 minutes at 0.3 Hz with the peak velocity of 30 deg/s and 60 deg/s, synchronized with both in-phase (gain decrease: x 0 experiment) and out-of-phase (gain increase: x 2 experiment) sinusoidal rotation of white-black stripe patterns. Subjects were 19 healthy adult volunteers with no history of neurological symptoms. Horizontal and vertical eye positions were recorded by bitemporal DC-coupled electrooculography. In the x 2 adaptation experiment with 0.3 Hz at the peak velocity of 30 deg/s, the percent change in gain (post-pre/ pre) was 110% at the same stimulation and 100% at 40 deg/s in EVA. In the x 0 adaptation experiment with 0.3 Hz at the peak velocity of 30 deg/s, the percent change in gain was -50% at the same stimulation in EVA. In the x 2 adaptation experiment with 0.3 Hz at the peak velocity of 60 deg/s, the percent change in gain was 66% at the same stimulation in EVA, 30% at the same stimulation in nose-up position, and 74% at the same stimulation in nose-down position. In the x 0 adaptation experiment with 0.3 Hz at the peak velocity of 60 deg/s, the percent change in gain was -34% at the same stimulation in EVA. No change in VOR gain was observed at other peak velocities. These results suggest that VOR adaptation depends frequency and maximum angular head velocity, and this characteristic is observed in OVAR.

Response: Combined testing of cardiac and carotid artery stenosis?

Response: Combined testing of cardiac and carotid artery stenosis?

Urgent carotid endarterectomy for stroke in evolution.

Carotid endarterectomy (CEA) is well established as the elective treatment for moderate or severe carotid stenoses with a history of neurologic symptoms. In contrast, the merits of carotid revascularisation performed in emergency in patients with acute stroke or fluctuating neurological deficit remain controversial. A total of 445 CEAs were performed on 424 patients for 212 (48%) asymptomatic and 233 (52%) symptomatic carotid stenoses within a 5 years period between January, 1995, and December, 1999. Of the latter, CEA was performed in emergency on 16 patients (3.8%) within 4 to 24 hours after the onset of symptoms. Patients selected for urgent surgery fulfilled the following criteria: acute onset of fluctuating hemispheric neurological symptoms, significant carotid pathology, absence of cerebral hemorrhage, uncompromised vigilance and stable cardiopulmonary conditions. Selected patients presented with a crescendo-TIA (n = 7) or fluctuating neurological deficits (n = 9) corresponding to a contralateral carotid stenosis. Following CEA, the neurological deficits improved instantaneously to complete recovery in 9 patients. The symptoms of 4 patients improved to non-disabling deficits, remained unchanged in one and worsened in 2 patients from hemihypaesthesia to hemiparesis. 14/16 patients were discharged within 8 days after admission. The neurologic status after discharge did not deteriorate in any of the patients during follow up of 19.3 +/- 13 months, but improved in 4 of the patients. Our retrospective study suggests that rescue CEA may be beneficial for selected patients with stroke in evolution and fluctuating neurological deficits. Careful adherence to selection criteria, intraoperative shunting, intensive care post surgery surveillance and an experienced team are recommended.

Magnetic resonance imaging evidence of “silent” cerebrovascular toxicity in cocaine dependence

Background: Cocaine and its metabolites can produce vasospasm. Cocaine-dependent (CD) patients are at increased risk for stroke, and a high frequency of brain perfusion defects has been observed in clinically asymptomatic CD subjects. This is the first controlled magnetic resonance imaging (MRI) study of clinically asymptomatic CD subjects. Methods: Two age-matched groups of male subjects (61 CD and 57 control) participated in the study. Subjects with a history of neurologic symptoms or major medical or neurologic illness, such as hypertension, diabetes, or significant head trauma, were excluded. The severity of hyperintense lesions observed on T2-weighted MRI images were rated on a 0–3-point scale by an experienced radiologist who was blind to all clinical data. Ratings of 3 were felt to be significant indicators of a possible disease process and were used in the data analysis. Three regions were separately rated: the cerebral white matter, subinsular white matter, and subcortical gray matter (basal ganglia and thalamus region). Results: Despite the exclusion criteria minimizing risk factors for cerebrovascular events, 17 of the 61 (27.9%) CD subjects and 4 of 57 (7%) of the control subjects had severe hyperintense lesions suggestive of subclinical or “silent” anoxic vascular events. Significant group differences were observed in the two white matter regions but not in the subcortical gray matter region. The risk of severe white matter lesions in the CD group increased with age, reaching 50% in the oldest age quartile (46–58 years), and this increase was not related to the number of years cocaine was used. Conclusions: The data suggest that asymptomatic CD patients are a heterogeneous population with a significantly increased age-related risk of white matter neurovascular toxicity. Premature neurovascular damage may impact treatment outcomes and, as the CD population ages, may manifest as an increased incidence of cognitive deficits.

99Tcm-HMPA0 SPET in diabetic patients with no history of neurological symptoms after activation with acetazolamide

99Tcm-HMPA0 SPET in diabetic patients with no history of neurological symptoms after activation with acetazolamide

Head trauma in children younger than 2 years: are there predictors for complications?

To determine the incidence of skull fracture (SF) and intracranial injury (ICA) among children younger than 2 years evaluated in a pediatric emergency department for head trauma; whether historical features and/or physical findings are predictive of injury type; and whether clinical criteria could allow a selective approach to radiographic imaging. Retrospective medical record review. Tertiary pediatric emergency department. Case series of 278 children aged younger than 24 months evaluated for head injury. Presence of SF and/or ICA. Diagnoses at discharge included 227 minor head injuries, 39 isolated SF, 9 ICA with SF, and 3 isolated ICA. Children younger than 12 months had the highest incidence of SF/ICA (29%) vs 4% for children aged 13 to 24 months (P<.001). Seven percent of complications from SF/ICA resulted from falls 3 ft (0.9 m) or less [corrected]. Incidence of behavioral change, loss of consciousness, emesis, and seizures did not differ significantly between those with minor head injuries and those with SF/ICA. Scalp abnormalities were more common in children with SF/ICA (P<.001). Sixty-two percent of children with isolated SF and 58% of children with ICA had no history of loss of consciousness, emesis, seizure, or behavioral change. Ninety-two percent of children with isolated SF and 75% of children with ICA had normal levels of consciousness and nonfocal neurologic examinations at diagnosis. Among children who fell 3 ft or less (0.9 m) [corrected] and had no loss of consciousness, emesis, seizure, behavioral change, or scalp abnormality, none of 31 (95% confidence interval [CI], 0-0.10) children younger than 24 months and none of 20 (95% CI, 0-0.15) children younger than 12 months had SF/ICA. Both SF and ICA are common in children younger than 2 years evaluated for head trauma. Children younger than 12 months are at highest risk. Injuries resulted from relatively minor falls and occurred in alert, neurologically normal children. Clinical signs and symptoms were insensitive predictors of SF/ICA; however, a grouping of features (fall < or = 3 ft [0.9 m], no history of neurologic symptoms, and normal scalp physical examination results) identified a subset of children at low risk for complications.

Preoperative thallium scanning, selective coronary revascularization, and long-term survival after carotid endarterectomy.

Long-term survival in patients after carotid endarterectomy (CEA) is determined mainly by their concomitant cardiac disease. We tested to determine whether preoperative thallium scanning (PTS) and subsequent selective coronary revascularization (CR), by either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG), improve long-term survival after CEA. Two hundred twenty-six of 255 consecutive patients (88%) undergoing CEA from 1990 to 1996 had PTS. Those with significant reversible defects on PTS were referred for coronary angiography and possible CR. Patients who had undergone PTS were divided into the following 4 groups: group 1, normal or mild defects on PTS; group 2, moderate-severe fixed and/or reversible defects in patients who did not undergo CR; group 3, patients who had CR secondary to their PTS results; and group 4, patients who had CR in the past that was not related to the PTS. Perioperative data were prospectively recorded, and data on long-term survival and cardiac and neurological complications were collected. Seventy-seven patients (34%) had preoperative coronary angiography, and 42 (19%) had subsequent CR: preoperative PTCA or CABG in 24, combined CEA+CABG in 10, and post-CEA CABG in 8 patients. No deaths resulted from the coronary angiography, CR, or CEA. Six patients had perioperative nonfatal myocardial infarction and 8 had stroke. During the follow-up (40+/-23 months), 47 patients (18%) died, 31 (66%) from cardiac disease and 4 (8.5%) from stroke. Independent predictors of long-term overall mortality were diabetes mellitus, preoperative T-wave inversion on ECG, lower-extremity arterial disease, and history of neurological symptoms [exp(beta)=3. 5, 3.4, 2.5, and 2.4; P=0.0003, 0.0004, 0.01, and 0.04, respectively]. In addition, preoperative moderate-severe thallium defect without CR (group 2) independently predicted long-term cardiac mortality [exp(beta)=2.8; P=0.04]. Patients with preoperative CR (group 3) had long-term survival rate similar to that of group 1 and significantly better than that of group 2 (P=0. 02). PTS predicts long-term survival, and selective CR based on the thallium results improves the survival rate of patients undergoing CEA.