Significant Neurological Improvement Research Articles

Thymoma resection and myasthenia gravis: what is the neurological outcome in patients older than 65years?

To increase the neurological results in patients older than 65years with myasthenia gravis after thymectomy, we retrospectively analysed this outcome in a large bicentric cohort of patients with myasthenia gravis (MG)years, for which surgery was indicated for a concurrent thymoma. From 1/2000 to 2/2022, 502 patients underwent thymectomy for thymic epithelial tumours (TETs) in two high-volume Institutions (167aged more than 65years). Among them, 66 patients were affected by TET and MG, representing our final study group. The mean age for MG onset was 68.3 ± 6years.At surgery, the Osserman score 2 was the most diffuse in our cohort (43, 65.1%), followed by 1 (20, 30.3%). In 11 cases, the MG diagnosis coincided with thymoma diagnosis. In the other cases, the interval between MG diagnosis and surgery was 1.7years ± 1.9. The most common surgical approach was sternotomy (41,62.1%), followed by RATS (14,21.2%). The most frequent TNM stage was T1N0 (75.7%) and most patients had WHO type-B tumour. After radical thymectomy, 58 patients (88%) reported a significant neurological improvement. According to MGFA-PIS, after surgery we had 4 (6%) complete stable remission, 11 (16.7%) pharmacological remission, 43 (65.2%) minimal manifestation, 2 (3%) worsening/death for MG, and 5 (7.6%) unchanged. No association was found between neurological outcome and age of MG onset, kind of pharmacological therapy before surgery, surgical approach (sternotomy vs others), tumour dimension, the ITMIG stage and the preoperative Osserman score. For MG and thymoma-afftected patients over 65years, thymectomy seems to be an effective treatment to improve neurological symptoms. We suggest to set up clinical trials to explore the neurological efficacy of mini-invasive thymectomy in clinically selected MG patients aged over 65years.

Diagnostic Accuracy of Somatosensory Evoked Potential and Transcranial Motor Evoked Potential in Detection of Neurological Injury in Intradural Extramedullary Spinal Cord Tumor Surgeries: A Short-Term Follow-Up Prospective Interventional Study Experience from Tertiary Care Center of India.

Objective Intraoperative neuromonitoring (IONM) is an acknowledged tool for real-time neuraxis assessment during surgery. Somatosensory evoked potential (SSEP) and transcranial motor evoked potential (MEP) are commonest deployed modalities of IONM. Role of SSEP and MEP in intradural extramedullary spinal cord tumor (IDEMSCT) surgery is not well established. The aim of this study was to evaluate sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and transcranial MEP, in detection of intraoperative neurological injury in IDEMSCT patients as well as their postoperative limb-specific neurological improvement assessment at fixed intervals till 30 days. Materials and Methods Symptomatic patients with IDEMSCTs were selected according to the inclusion criteria of study protocol. On modified McCormick (mMC) scale, their sensory-motor deficit was assessed both preoperatively and postoperatively. Surgery was done under SSEP and MEP (transcranial) monitoring using appropriate anesthetic agents. Gross total/subtotal resection of tumor was achieved as per IONM warning alarms. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP were calculated considering postoperative neurological changes as "reference standard." Patients were followed up at postoperative day (POD) 0, 1, 7, and 30 for convalescence. Statistical Analysis With appropriate tests of significance, statistical analysis was carried out. Receiver-operating characteristic curve was used to find cutoff point of mMC for SSEP being recordable in patients with higher neurological deficit along with calculation of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP for prediction of intraoperative neurological injury. Results Study included 32 patients. Baseline mean mMC value was 2.59. Under neuromonitoring, gross total resection of IDEMSCT was achieved in 87.5% patients. SSEP was recordable in subset of patients with mMC value less than or equal to 2 with diagnostic accuracy of 100%. MEP was recordable in all patients and it had 96.88% diagnostic accuracy. Statistically significant neurological improvement was noted at POD-7 and POD-30 follow-up. Conclusion SSEP and MEP individually carry high diagnostic accuracy in detection of intraoperative neurological injuries in patients undergoing IDEMSCT surgery. MEP continues to monitor the neuraxis, even in those subsets of patients where SSEP fails to record.

Optimal Timing in Cervical Spinal Cord Injury: A Comprehensive Meta-Analysis of Ultra-Early Surgical Intervention Within Five Hours.

The optimal timing of surgery for cervical spinal cord injuries (SCI) and its impact on neurological recovery continue to be subjects of debate. This systematic review and meta-analysis aims to consolidate and assess the existing evidence regarding the efficacy of ultra-early decompression surgery in improving clinical outcomes after cervical SCI. A search was conducted in PubMed, Embase, Cochrane, and CINAHL databases from inception until September 18, 2023, focusing on human studies. The groups were categorized into ultra-early decompression (decompression surgery ≤ 5 hours post-injury) and a control group (decompression surgery between 5-24 hours post-injury). A random effects meta-analysis was performed on all studies using R Studio. Outcomes were reported as effect size (OR, treatment effect, and 95% CI. Of the 140 patients, 63 (45%) underwent decompression ≤ 5 hours, while 77 (55%) underwent decompression > 5 hours post-injury. Analysis using the OR model showed no statistically significant difference in the odds of neurological improvement between the ultra-early group and the early group (OR = 1.33, 95% CI: 0.22-8.18, p = 0.761). This study did not observe significant neurological improvement among cervical SCI patients who underwent decompression within five hours. Due to the scarcity of literature on the ultra-early decompression of cervical SCI, this study underscores the necessity for additional investigation into the potential benefits of earlier interventions for cervical SCI to enhance patient outcomes.

Urgent Carotid Endarterectomy for Stroke: A Case Report

Urgent carotid endarterectomy (CEA) is beneficial in patients with non-disabling stroke or transient ischemic attack and significant ipsilateral carotid artery stenosis. It is recommended to be performed within 2-4 weeks of the event; however, its safety when done within 48 hours is still under investigation with potential risks of recurrent ipsilateral stroke and death being reported. This case highlights that urgent CEA done within 48 hours can result in significant neurological improvement. NICE advises within 48 hours of diagnosis and <7 days of radiological imaging while some large studies- especially a Swedish study of >2000 patients concluded an increased risk of stroke and death when performed within 48 hours. Evidence is still developing. In selected cases, this timely intervention can be the standard of care in the Caribbean setting in keeping with international best practice.

Safety and efficacy of day anterior cervical discectomy and fusion procedure for degenerative cervical spondylosis: a retrospective analysis

ObjectiveOur study aimed to develop a day anterior cervical discectomy and fusion (ACDF) procedure to treat degenerative cervical spondylosis (DCS). The goal was to analyze its clinical implications, safety, and early effects to provide a better surgical option for eligible DCS patients.MethodsA retrospective analysis was performed to identify DCS patients who underwent day ACDF from September 2022 to August 2023. The operative time, intraoperative blood loss, postoperative drainage, preoperative and postoperative visual analog scale (VAS) scores, neck disability index (NDI) scores, Japanese Orthopedic Association (JOA) scores, JOA recovery rate (RR), incidence of dysphagia-related symptoms, 30-day hospital readmission rate, and incidence of other complications were recorded to evaluate early clinical outcomes. Radiography was performed to assess the location of the implants, neurological decompression, and cervical physiological curvature.ResultsAll 33 patients (23 women and 10 men) underwent successful surgery and experienced significant symptomatic and neurological improvements. Among them, 26 patients underwent one-segment ACDF, 5 underwent two-segment ACDF, and 2 underwent three-segment ACDF. The average operative time was 71.1 ± 20.2 min, intraoperative blood loss was 19.1 ± 6.2 mL, and postoperative drainage was 9.6 ± 5.8 mL. The preoperative VAS and NDI scores improved postoperatively (7.1 ± 1.2 vs. 3.1 ± 1.3 and 66.7% ± 4.8% vs. 24.1% ± 2.5%, respectively), with a significant difference (P < 0.01). Moreover, the preoperative JOA scores improved significantly postoperatively (7.7 ± 1.3 vs. 14.2 ± 1.4; P < 0.01) with an RR of 93.9% in good or excellent. Postoperative dysphagia-related symptoms occurred in one patient (3.0%). During the follow-up period, no patient was readmitted within 30 days after discharge; however, an incisional hematoma was reported in one patient on the 6th day after discharge, which was cured by pressure dressing. The postoperative radiographs revealed perfect implant positions and sufficient nerve decompression in all patients. Furthermore, the preoperative cervical physiological curvature improved significantly after the operation (14.5° ± 4.0° vs. 26.3° ± 5.4°; P < 0.01).ConclusionsDay ACDF has good safety and early clinical efficacy, and it could be an appropriate choice for eligible DCS patients.

The negative impact of treatment delays on the long-term neurological outcomes of spinal dural arteriovenous fistulas: a longitudinal cohort study.

Dural arteriovenous fistulas are rare vascular malformations that affect the brain and spinal cord. Spinal dural arteriovenous fistulas (sdAVFs) are the most frequently encountered vascular malformation affecting the spinal cord. The object of this study was to evaluate the impact of treatment delays on the long-term neurological outcomes of either open surgical or interventional treatment of sdAVFs. In this retrospective, population-based cohort study, the authors examined consecutive patients with diagnosed sdAVFs at a tertiary care center between 2005 and 2020. Patients were assessed using the Aminoff-Logue disability scale (ALS) at various time points including symptom onset, primary care visit, first specialist outpatient visit, as well as both short and long-term follow-ups. The postoperative long-term ALS gait and bladder grades constituted the primary outcomes of the study. Among the 34 patients included in the study, the median age was 65 years, and there was a male predominance (71%). Most lesions were in the lumbar region (47%). Significant worsening in ALS gait and bladder grades was observed preoperatively, followed by postoperative improvements (p < 0.05). There was no difference in outcomes between surgical and endovascular treatments. Older age (OR 1.10, 95% CI 1.03-1.17, p = 0.007), worse preoperative ALS gait grades (OR 5.12, 95% CI 2.18-12.4, p < 0.001), and longer time from first specialist outpatient visit to first treatment (OR 1.00, 95% CI 1.00-1.01, p = 0.040) were independently associated with worse long-term gait outcomes. Only the preoperative ALS bladder score was a predictor of worse long-term bladder function (OR 92.7, 95% CI 28.0-306.7, p < 0.001). Both surgical and endovascular treatments for sdAVFs led to significant neurological improvements. However, treatment delays were associated with less favorable long-term outcomes. Prompt diagnosis and early intervention prior to symptom progression may enhance recovery and help to preserve neurological function.

The clinical outcome of emergency superficial temporal artery-to-middle cerebral artery bypass in acute ischemic stroke with large vessel occlusion

The role of superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass in acute ischemic stroke (AIS) is contentious, with no evidence in patients with AIS and large vessel occlusion (AIS-LVO). We conducted a cohort study to assess emergency STA-MCA outcomes in AIS-LVO and a meta-analysis to evaluate STA-MCA outcomes in early AIS treatment. From January 2018 to March 2021, we consecutively recruited newly diagnosed AIS-LVO patients, dividing them into STA-MCA and non-STA-MCA groups. To evaluate the neurological status and outcomes, we employed the National Institutes of Health Stroke Scale (NIHSS) during the acute phase and the modified Rankin Scale (mRS) during the follow-up period. Additionally, we conducted a meta-analysis encompassing all available clinical studies to assess the impact of STA-MCA on patients with AIS. In the cohort study (56 patients), we observed more significant neurological improvement in the STA-MCA group at two weeks (p = 0.030). However, there was no difference in the clinical outcomes between the two groups. Multivariable logistic regression identified the NIHSS at two weeks (OR: 0.840; 95% CI: 0.754–0.936, p = 0.002) as the most critical predictor of a good outcome. Our meta-analysis of seven studies indicated a 67% rate for achieving a good outcome (mRS < 3) at follow-up points (95% CI: 57%–77%, I2 = 44.1%). In summary, while the meta-analysis suggested the potential role of STA-MCA bypass in mild to moderate AIS, our single-center cohort study indicated that STA-MCA bypass does not seem to improve the prognosis of patients who suffer from AIS-LVO.

Complete C4-C5 Dislocation Secondary to Shallow Water Diving in a Child: A Case-Based Update

Abstract Introduction Pediatric spinal cord injury (PSCI) is rare, especially secondary to shallow water diving, with only a few cases recorded in the literature. Due to the low standardization in the diagnosis and treatment of this condition, each of these cases requires a personalized approach. Case Description A 10-year-old female patient presented with tetraparesis and C5 sensory level secondary to spinal trauma due to shallow water diving. Computed tomography (CT) revealed complete C4-C5 dislocation, which led to a neurosurgical approach preceded by an intraoperative manual maneuver to reduce the dislocation. Following complete surgical reduction of the dislocation, the patient presented immediate significant neurological improvement. Conclusion Children need to be warned about diving, as SCI due to shallow water diving has a poor neurological outcome. Despite that, early diagnosis, stabilization, and surgical approach can lead to immediate significant neurological improvement. Considering the peculiarities of pediatric patients and the existence of varying care techniques in the literature, more studies comparing surgical and nonsurgical outcomes are fundamental.

Chronic acquired polyneuropathy as presentation of skull based solitary bone plasmacytoma

Plasmacytomas can be solitary or multiple (osteosclerotic myeloma). Neuropathy resembling chronic inflammatory demyelinating polyradiculoneuropathy or POEMS syndrome has rarely been reported in literature in association of cranial vault plasmacytoma. A female patient with severe demyelinating sensori-motor polyneuropathy with conduction block, was found to have solitary skeletal lesion in the left frontal bone which confirmed to be a plasma cell neoplasm on biopsy. She had significant improvement in neurological signs and symptoms following local radiation and chemotherapy over next 3 months. Solitary bone plasmacytoma (SBP) is rare, accounting for 2-5% of all plasma cell neoplasms. The axial skeleton, especially vertebral body, is the most common site and cranial vault is one of the least commonly reported. Radiation therapy (RT) is the treatment of choice for SBP. There is no evidence that plasma exchange, IVIg or other immunosuppressive agents are effective when used alone in treatment of SBP-associated neuropathy.

Location-specific technical nuances of spinal meningioma resection: an operative video case series.

The objective of this video was to demonstrate technical nuances of intradural spinal meningioma (ISM) resection through a high-quality surgical video. The authors describe 3 patients with ISM in the cervicomedullary, cervical, and thoracic regions. Patients underwent surgery in the prone position with laminectomy, dorsal durotomy, and then resection of the mass. Case 1 required a suboccipital craniectomy and dissection of the tumor away from the vertebral artery. In case 2, special emphasis is placed on sectioning the dentate ligament with cord rotation. Case 3 highlights meticulous circumferential arachnoid release and the use of ultrasound. Patients saw significant neurological improvement postoperatively. This video provides clear instruction on location-specific technical nuances of ISM removal.

High neutrophil-to-lymphocyte ratio (NLR) predicts poor response to intravenous thrombolysis in white Caucasian stroke patients

ObjectivesOur aim was to investigate usefulness of the neutrophil-to-lymphocyte ratio (NLR) for predicting poor response to intravenous rtPA in white Caucasian ischemic stroke patients treated within 4.5 hours from the onset. Materials and methodsThis retrospective analysis included all consecutive acute ischemic stroke patients (N = 344) treated with rtPA in a tertiary stroke center from 2011 to 2017. NLR was calculated from complete blood counts obtained on admission. The patients were classified into NLR terciles (T1 <1.75, T2<2.97, T3≥2.97). Significant neurological improvement was defined as an 8-point reduction in the NIHSS score or reaching the score of 0 to 1. ResultsCompared to NLR T1, patients from NLR T3 were significantly older, more often disabled before stroke, and had longer onset-to-needle time. They less often achieved neurological improvement at day 7 (38% vs 59% p=0.002) and had higher 90-day mortality (27% vs 13%, p=0.020), with no differences in neurological improvement at 24 hours, occurrence of sICH and 7–day mortality. Each additional 4 units of NLR decreased unadjusted and adjusted odds for achieving favorable outcome at day 7 (OR 0.65, 95% CI: 0.46-0.92; aOR 0.62, 95% CI: 0.39-1.00), and increased the odds for death at 3 months (OR 1.60, 95% CI: 1.15-2.24; aOR 1.82, 95% CI:1.14-2.92) ConclusionsHigh NLR can predict poor response to intravenous rtPA in Caucasian patients with acute ischemic stroke, especially in terms of not achieving significant neurological improvement at day 7 and death at day 90. It encourages attempts to incorporate NLR in already validated scores.

Surgical strategies for the treatment of deformity-associated cervical spondylotic stretch myelopathy: a case series with technically nuanced illustrative operative videos.

The aim of this study was to elucidate the vital role of anterior-only osteotomies for rigid cervical kyphosis causing stretch myelopathy by using illustrative cases and high-definition intraoperative videos. The authors describe 4 select patients who underwent anterior-only osteotomies within a 2-year time frame and demonstrate the nuances of each case with unique operative videos. Outcomes for each of the cases demonstrated marked improvement in cervical spine alignment relative to preoperative conditions. Postoperative CT scans and upright radiographs for case 1 at 8 months demonstrated complete reduction of the kyphotic deformity and restoration of the C2 slope. In case 2, the 2-year postoperative radiographs showed significant realignment of the cervical spine, and the patient made significant neurological improvement since the operation, specifically in hand dexterity, balance, neck pain, and the ability to comfortably achieve and maintain a horizontal gaze. For case 3, postoperative upright radiographs revealed marked improvement in the patient's cervical sagittal alignment. The 4-month follow-up was also notable for substantial improvement in postural neck pain, bilateral upper extremity strength, and continued improvements in dexterity. Case 4 also demonstrated an excellent outcome with unkinking of the patient's spinal cord and correction of her sagittal plane deformity, as shown on her 5-month postoperative upright radiographs. Deformity-associated cervical spondylotic stretch myelopathy often leads to devastating neurological decline and can significantly decrease quality of life. Carefully selected cases of circumferentially rigid cervical kyphosis can be successfully corrected with anterior-only osteotomies followed by posterior fixation while avoiding back-front-back operations.

Neuromyelitis Optica Spectrum Disorder Mimicking Pontine Stroke - A Cautionary Tale: Case Report and Systematic Literature Review (P13-5.014)

<h3>Objective:</h3> To report an unusual clinical pattern of Neuromyelitis Optica Spectrum Disorder (NMOSD) presenting as a pontine stroke mimic <h3>Background:</h3> A 58-year-old Hispanic woman presented to an outside hospital with right-sided numbness, blurry vision, and gait instability. Findings on brain MR imaging were thought to reflect acute pontine stroke; the patient commenced dual antiplatelet therapy. Three weeks later, she presented to our hospital with right-sided hemiparesis. Stroke workup was unrevealing for specific pathophysiology. She was readmitted about two weeks later with a new-onset right cranial nerve VI palsy with ipsilateral facial droop and tinnitus. Brain MRI demonstrated foci of diffusion restriction on DWI in the periventricular white matter and brainstem region suggesting rhombencephalitis of inflammatory or autoimmune origin. Despite IVIG infusion, the patient’s condition deteriorated and she was intubated for airway protection. Serological assays were positive for AQP4 and negative for all other autoantibodies, including anti-Gq1b. She was treated with methylprednisolone pulse dosing and plasmapheresis, followed by rituximab, with significant neurological improvement. <h3>Design/Methods:</h3> In addition to the case report, a systematic literature review was performed to identify NMOSD cases initially diagnosed as stroke. Publications were selected and curated in accordance with PRISMA guidelines. <h3>Results:</h3> Six NMOSD patients were initially thought to represent acute stroke. However, the persistence, progression, or recurrence of symptoms with additional history, follow-up neuroimaging, and further serological immune assays facilitated the accurate diagnosis of NMOSD. Notably, the age of onset in all cases was significantly more advanced than patients normally presenting with NMOSD (median age 32–41). <h3>Conclusions:</h3> NMOSD diagnosis should be considered in individuals presenting with atypical stroke-like symptoms, particularly in those greater than or equal to 41 years of age. This is important as early recognition and treatment with immune therapies can improve functional outcome. <b>Disclosure:</b> Dr. Huang has nothing to disclose. Dr. Arora has nothing to disclose. An immediate family member of Dr. Diamond has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Consultant360. An immediate family member of Dr. Diamond has received publishing royalties from a publication relating to health care. Dr. McFarlane has nothing to disclose. Dr. Najjar has nothing to disclose.

Sudden Death in Autoimmune GFAP Astrocytopathy (P5-5.020)

<h3>Objective:</h3> To describe a rare fatal outcome in autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. <h3>Background:</h3> Our patient was a 42 year old healthy woman who presented with 3 months of low back pain, bilateral upper extremity postural tremor, neck pain which progressed to 1 week of confusion and memory impairment. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> Neurologic exam revealed impaired attention, 3+ deep tendon reflexes throughout, bilateral upper extremity postural tremor and narrow based gait. MRI Brain showed abnormal, diffuse and relatively symmetric periventricular linear enhancement with associated subependymal enhancement. MRI C-spine demonstrated longitudinally extensive T2 FLAIR hyperintensity extending from C2–T2. Lumbar puncture showed opening pressure of 19 cm H2O with lymphocytic pleocytosis. She was treated with 5 days of pulse-dose corticosteroids with significant neurologic improvement and was discharged on prednisone taper. She was at her neurological baseline at Neuroimmunology clinic a week after the discharge. In the interim, CSF studies returned positive for GFAP antibody. Two weeks after the visit, she had new-onset word-finding difficulties, forgetfulness and intermittent staring spells. She was started on prednisone 60 mg daily and had repeat lumbar puncture at the office. Four to five hours after the lumbar puncture, she developed worsening confusion and bilateral upper extremity shaking. She was brought to our ED where her exam revealed dilated pupils with minimal reaction to light. CT head and CTA of the head and neck showed diffuse cerebral edema with absent cortical blood flow. Death by neurologic criteria was met the next day. <h3>Conclusions:</h3> Autoimmune GFAP astrocytopathy has an overall favorable prognosis. Our patient had a fatal outcome secondary to cerebral herniation following lumbar puncture, similar to the first reported fatal case. These two cases suggest that autoimmune GFAP astrocytopathy may present with diffuse cerebral edema and caution should be taken when performing lumbar punctures when this disease is suspected or diagnosed. <b>Disclosure:</b> Dr. Mahat has nothing to disclose. Dr. Dermigny has nothing to disclose. Dr. Alzyoud has nothing to disclose. Dr. Pilato has nothing to disclose.

Manual therapeutic plasma exchange for treatment of a dog with suspected acute canine polyradiculoneuritis

BackgroundAcute canine polyradiculoneuritis is one of the most common polyneuropathies occurring in dogs. The disease is very similar to the Guillain–Barré syndrome in humans. In veterinary medicine, there is no established treatment for this disease, while in human medicine, therapeutic plasma exchange and intravenous immunoglobulin administration are two main immunotherapy treatments of this syndrome.Case presentationA 12-year-old male Jack Russel Terrier was presented with a history of acute weakness of the pelvic limbs progressing to flaccid tetraplegia with respiratory compromise. Complete diagnostic workup was performed including blood work, diagnostic imaging (radiographs of the thorax as well as ultrasound of the abdomen) and echocardiography. Based on the clinical course, neurological localisation and the results of electrodiagnostic examination acute canine polyradiculoneuritis was suspected. During the hospitalization, the dog deteriorated and was admitted to the intensive care unit for respiratory support via tracheostomy tube. In addition to symptomatic treatment, immunotherapy via single treatment of manual therapeutic plasma exchange was administered. This procedure was safe, and the dog showed improvement of clinical signs 3 days after therapy was initiated, as well as improvement of neurological signs (from grade 4 tetraplegia to grade 3) within 5 days. However, the dog was euthanized 3 weeks later due to complications related to the tracheostomy.ConclusionsThis is the first case report of a manual therapeutic plasma exchange in a dog with suspected acute canine polyradiculoneuritis suggesting that this method is safe and well tolerated in dogs with this disease. It may be a reasonable adjunctive treatment to supportive therapy in severe cases.

Abstract Number ‐ 114: Deep Cerebral Venous Thrombosis requiring Venous Thrombectomy and Intra‐arterial Thrombolysis in Young Pregnant Female

Introduction Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and mortality especially in young women and children (1). Even though, first‐line treatment remains anticoagulation, some patients deteriorate and endovascular treatment is needed. Currently there are no randomized controlled trials comparing the efficacy and safety of intracranial thrombolysis and mechanical thrombectomy to standard‐of‐care anticoagulation therapy (2). We present a case of a pregnant lady with CVST with successful clinical outcomes with venous thrombectomy and intraarterial thrombolysis. Methods Case Report Results 30 year old lady with no past medical history, 7 weeks and 4 days pregnant presented with acute progressive encephalopathy associated with nausea, vomiting and headaches. On admission, she was stuporous, had dysarthria, severe hemiparesis, and hemineglect on the right side. She had COVID‐19 infection and her fetus had subchorionic hematoma by ultrasound. Initial CT brain showed extensive cerebral venous sinus thrombosis (CVST). She was intubated and MRI showed venous infarcts. MR venography revealed acute extensive CVST of superior sagittal sinus, vein of galen, right transverse sinus, right sigmoid sinus, and right jugular vein. IV Heparin drip was initiated. Her follow‐up neurological exam deteriorated despite maximal medical therapy. The decision was made for endovascular recanalization. The cerebral angiogram confirmed the occlusion of deep venous system. Thrombectomy of bilateral internal jugular vein and sigmoid sinus was performed with retrieval of thrombi. Post‐thrombectomy runs demonstrated persistent extensive CVST and decision was made for intra‐arterial thrombolysis. A diagnostic catheter was secured in the right internal carotid artery catheter (ICA). Thombolysis was performed with 4 mg/hr recombinant tissue‐plasminogen activator (rt‐PA). Heparin drip IV was continued. Subsequently, the repeat CT brain showed significant improvement in the CVST and interval development of intraparenchymal hemorrhages and subarachnoid hemorrhages. Heparin and rt‐PA were held. The patient was found to have Factor V Leiden mutation and she was started on Enoxaparin 1mg/kg throughout her pregnancy and 6 weeks postpartum. Clinically she demonstrated significant neurologic improvement and was discharged to home from rehabilitation center. Currently, she is thirty‐ four weeks pregnant and neurologically intact without any deficits. Conclusions Pharmacological and mechanical endovascular interventions can have significantly successful clinical outcomes in deep cerebral venous thrombosis. Controlled studies are required to assess the safety and efficacy of these interventions when compared to standard systemic anticoagulation.

Multilevel ossification of the posterior longitudinal ligament causing cervical myelopathy: An observational series of North American patients.

Few studies regarding ossification of the posterior longitudinal ligament (OPLL) outside of Asia currently exist in the literature. A set of patients with multilevel cervical OPLL causing symptomatic myelopathy or radiculopathy from a North American sample is analyzed. The objective of this study was to describe the demographics, radiographic findings, and surgical outcomes of a cohort of North American patients with degenerative spondylosis presenting for operative management of multilevel (>3 segments) cervical OPLL. Forty-three patients diagnosed with multilevel cervical OPLL and degenerative spondylosis presenting with symptomatic cervical myelopathy or radiculopathy were surgically treated over a 9-year period at a single tertiary care academic medical center. Radiographic measurements were performed on preoperative computed tomography and magnetic resonance imaging images of the cervical spine. Clinical outcomes included pre- and postoperative Nurick scores, 90-day readmission, complication, and revision surgery rates. The mean age was 66.1 ± 10.9 years with a mean latest follow-up time of 32.7 ± 16.4 months. Most patients had previous diagnoses of obesity (70.7%) and hypertension (55.8%). At least one-quarter of patients were diagnosed with type 2 diabetes (34.9%), hyperlipidemia (41.9%), cardiovascular disease (25.6%), or chronic kidney disease (25.3%). The most common OPLL subtype was segmental (39.5%) and spanned a mean of 3.54 ± 1.48 segments. Myelopathic symptoms were present in 88.4% of patients. All patients experienced significant neurologic improvement at 3-week and latest follow-up (P < 0.001 for both). Obesity, diabetes, and other metabolic derangements in patients with existing cervical spondylosis may be risk factors for a particularly aggressive form of multilevel OPLL. Various operative approaches may be employed to achieve adequate neurologic recovery. Further workup for OPLL in patients with these risk factors may prove beneficial to ensure appropriate operative management.

NEUROLOGICAL RECOVERY AFTER SURGICAL TREATMENT IN PATIENTS WITH THORACOLUMBAR TRM

ABSTRACT Objective: Evaluate the neurological recovery with a follow-up of 06 (six) months in victims of thoracic and lumbar fractures who underwent spinal decompression in less than 24 hours, between 24 and 48 hours, and more than 48 hours after the trauma. Methods: Data were collected on patients seen at a large public hospital in Belo Horizonte, between 2014 and 2018, who were victims of SCI who presented with neurological deficits at initial care, and the neurological recovery presented. Results: 41 SCI patients were evaluated, whose mean age was 34 years. There was a predominance of thoracic spine fractures (65.9% of the cases) and classified as AO Spine type C (75%). Regarding the time variable, about 68% of the patients were submitted to surgical treatment more than 48 hours after the trauma. It was observed that both the patients submitted to surgical decompression within less than 24 hours, and those operated on more than 48 hours after the trauma showed a slight neurological improvement at the 6-month follow-up. However, no statistical significance was found. It is worth noting that even when analyzing the 41 patients of the study, regardless of the surgical interval, it was impossible to observe a statistically significant neurological improvement at the 6-month follow-up. Conclusion: Our study could not demonstrate significant differences between those patients who operated early in less than 24 hours and those who operated after more than 48 hours. Level of Evidence III; Comparative retrospective study.

Timing of Recovery After Surgery for Patients With Degenerative Cervical Myelopathy: An Observational Study From the Canadian Spine Outcomes and Research Network.

The time course over which postoperative neurological recovery occurs after surgery for degenerative cervical myelopathy occurs is poorly understood. To determine the time point at which patients experience significant neurological improvement. We reviewed data from an ongoing prospective multicenter cohort study. We measured neurological function at 3 months, 1 year, and 2 years after surgery using the modified Japanese Orthopedic Association (mJOA) scale. We implemented minimal clinical important differences (MCIDs) to guide interpretation of mJOA scores, and we used 1-way analysis of variance to compare changes between follow-up intervals. Among 330 patients, the mean overall mJOA improved from 12.9 (SD 2.6) to 14.6 (SD 2.4) at 3 months, 14.7 (SD 2.4) at 1 year, and 14.8 (SD 2.5) at 2 years. The difference in means was statistically significant (P < .01) at the interval from baseline to 3 months postoperatively, but not from 3 months to 1 year or 1 year to 2 years. The MCID was reached by 161 patients at 3 months, 32 more at 1 year, and 15 more at 2 years, with a statistically significant difference only at 3 months. Patients with moderate or severe disease reached the MCID more frequently than those with mild disease. Among patients who underwent surgery for degenerative cervical myelopathy, most significant neurological improvement occurred by 3 months after surgery. These findings will facilitate valid discussions about postoperative expectations during shared clinical decision making between patients and their surgeons.

Prognostic factors and outcomes of surgical intervention for patients with spinal metastases secondary to lung cancer: an update systematic review and meta analysis.

Lung cancer is one of the most common malignant tumors. Most patients develop spinal metastases during the course of cancer and suffer skeletal-related events. Currently, no consensus has been reached on the prognostic factors in patients undergoing surgeries. This study aimed to answer two questions: (1) what are the effects of surgical intervention, and (2) what are the factors associated with postoperative survival. Searches were performed on electronic databases including PubMed, Ovid/MEDLINE, Cochrane, and Scopus for articles published before February of 2022, involving the survival factors of patients with spinal metastasis. Multiple data items were considered, such as baseline demographics, surgical details, clinical outcome, and prognostic factors. The analysis was performed in Review Manager (RevMan) 5.5. The prognostic factors of survival were analyzed with univariate and multivariate cox regression analysis. Finally, 14 studies with 813 patients were identified. Their 6, 12, and 24months survival rates ranged from 18 to 58%, 18 to 22.4%, and 0 to 58.5%, respectively. The pooled hazard ratio of preoperative ambulatory status and the number of involved vertebrae demonstrated statistical significance, while no significant prognostic effect on the overall survival was found for targeted therapy, visceral metastases, chemotherapy, radiotherapy, or postoperative ambulatory status. Overall, surgical intervention could achieve significant pain relief and neurological function improvements. For patients receiving surgery for spinal metastasis from lung cancer, preoperative ambulatory status and the number of involved vertebrae were significant prognostic factors associated with their survival.