Inferior Limb Research Articles

ACQUIRED VON WILLEBRAND SYNDROME SECONDARY TO MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE: LONG-TERM REMISSION AFTER TREATMENT WITH BORTEZOMIB

To describe a case report of a patient with monoclonal gammopathy of undetermined significance (MGUS) who progressed to Acquired von Willebrand syndrome (AVWS) and was successfully treated with bortezomib. Case report with literature review. A 54-years-old woman presented at our center to investigate an M-spike. She had been treated for chronic kidney disease due to glomerulonephritis for eight years and was on peritoneal dialysis waiting for a kidney transplant. During laboratory workup, a serum M-protein (0.3 g/dL) was detected by protein electrophoresis and a monoclonal IgG kappa was identified. After one year of follow-up, and with stable M-protein levels, the patient started complaining of increased bleeding from minor wounds, bruises in inferior limbs and repeated episodes of epistaxis. The patient had no personal or family history of bleeding disorders. Laboratory testing included normal blood and platelet counts, normal prothrombin and thrombin time but increased activated partial thromboplastin time (APTT ratio 1.62). Mixing study results showed APTT correction. Factor VIII coagulant activity (FVIII:C) was 12% but no inhibitor was detected. Von Willebrand factor antigen (vWF:Ag) was 10% and ristocetin cofactor activity (vWF:RCo) was 3%, with a vWF:RCo/vWF:Ag ratio of 0.3. Given the absence of previous personal and family history of bleeding and the diagnosis of MGUS, the diagnostic hypothesis of AWVS was made. To confirm this hypothesis, we performed a recovery test after infusion of von Willebrand factor (vWF 50 UI/kg), which results were suggestive of increased vWF clearance. The patient required treatment only after three years of AVWS diagnosis due to severe lingual hematoma. She was treated with two units of packed red blood and immunoglobulin (0.4g per kg for five days), with successful bleeding control. vWF:Ag, vWF:RCo and FVIII:C levels were also increased but returned to baseline values after three weeks. Because the patient was scheduled to undergo a kidney transplantation and the high risk of bleeding could lead to graft loss, it was decided to treat the MGUS-associated AVWS. She was treated with three cycles of dexamethasone 20 mg and cyclophosphamide 300 mg with no response. A second line treatment was started with dexamethasone 12 mg and bortezomib 1.5mg/m2 for a total of five cycles. After the end of the treatment, APTT, vWF:Ag, vWF:RCo results normalized and monoclonal paraprotein was eradicated. The patient was submitted to a kidney transplantation without bleeding complications. Two years after the end of the treatment, she remains in remission, with undetectable monoclonal paraprotein and normal coagulation and VWF tests. MGUS-associated AWVS is a rare bleeding disorder, and few data is available on the best treatment approach. We reported a case that transiently responded to immunoglobulin. This response, however, was not sufficient to warrant hemostatic levels of vWF required for kidney transplantation. Treatment of MGUS with bortezomib and dexamethasone led to eradication of the M-spike and normalization of the coagulation parameters. This response was durable, as the patient remains in remission of both MGUS and AWVS two years after the end of the treatment. This particular case highlights the importance of treating the underlying cause of the coagulopathy once the remission of AVWS only occurred after monoclonal gammopathy was controlled.

Clinical Implications of Diabetic Peripheral Neuropathy in Primary Infrapopliteal Angioplasty Approach for Neuro-Ischemic Foot Wounds.

To assess the clinical effects of diabetic peripheral neuropathy (DPN) in patients with chronic limb-threatening ischemia (CLTI) treated by primary infrapopliteal angioplasty for neuro-ischemic Rutherford 5, foot wounds. Over a 10-year period (2009-2019), a series of 304 diabetic ischemic limbs adding or not evincible neuropathic affectation were treated by primary infrapopliteal angioplasty and their files were retrospectively reviewed. Mean length of treated arterial lesions was 6.1 cm (range 1-22 cm). Inferior limb vibration perception threshold diagnostic was performed for comparing and scoring detectable DPN in all studied diabetic patients (classed from 0 to 10 points). There were 19% limbs with normal (0-1 points) perception (group 1), 55% others with "mild" and "moderate" (2-6 points) neuropathic impairment (group 2), and 26% limbs showing "severe" (7-10 points) DPN (group 3). Primary infrapopliteal angioplasty succeeded in 89% cases in group 1, in 82% in group 2, and in 68% of limbs in group 3. This latest group assembled the heaviest neuropathic affectation and arterial calcifications and proved the lowest clinical benefit at 36 months: 35% (95% confidence interval [CI]=22% to 48%) of primary patency, 36% (95% CI=22% to 50%) wound healing, and 54% (95% CI=39% to 69%) limb preservation rates. A comparison between groups 1 vs 3 and 2 vs 3 of primary patency (p=0.014 and p=0.043), tissue healing (p=0.049 and p=0.01), and limb salvage (p=0.006 and p=0.023) proved significant, yet without statistical weight for group 1 vs 2 (p>0.05). Overall survival was not significantly affected between groups (p=0.34). The presence of severe DPN may jeopardize the results of infrapopliteal angioplasty in terms of patency, tissue cicatrization, and limb preservation, yet without significance on survival of these patients. When present, DPN requires appropriate stratification as specific indicator in CLTI treatment.

Generalized joint hypermobility does not influence 1-year patient satisfaction or functional outcome after ACL reconstruction

PurposeThe purpose of this study was to evaluate whether generalized joint hypermobility (GJH) influences postoperative results, including return to sport, patientreported outcomes, functional performance (hop tests), muscular strength, and the occurrence of ACL re-injury, in patients 1 year after anterior cruciate ligament (ACL) reconstruction.MethodsData was extracted from a regional rehabilitation-specific registry containing information on patients with ACL injury. Patients between the ages of 16–50 years previously undergoing ACL reconstruction with available 1 year follow-up data were eligible for inclusion. Generalized joint hypermobility was assessed using the Beighton score (BS). Patients were examined one year postoperatively in terms of return to sport, patient-reported outcome, hop tests, muscular strength and the occurrence of reinjury. For purpose of analysis, patients were allocated into two groups, depending on the existence of GJH. The KOOS subscale of sports and recreation was considered the primary outcome. Analyses were performed both dichotomously and by using adjusted logistic regression, to consider potential confounders.ResultsA total of 356 patients (41% males) were included, of which 76 (24% male) were categorized as having GJH. Patients with GJH had an inferior limb symmetry index preoperatively in terms of knee extension (mean 81.6 [SD 16.4] vs. 91.4 [SD 15.9], p = 0.02) and flexion strength (mean 91.9 vs. 99.1, p = 0.047) compared to patients without GJH. There was no difference between the groups in terms of the primary outcome, nor in any of the other postoperative outcomes. Nine patients (11.8%) in the group with GJH suffered ACL re-injury, compared with 13 patients (4.6%) in the control group (n.s.).ConclusionOne year after ACL reconstruction the existence of GJH did not affect postoperative patient satisfaction, strength or functional outcome. No conclusive statements can be made regarding the influence of GJH on the risk of ACL re-injury in this particular study.Level of evidenceLevel II.

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel–Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black’s “Checklist for Measuring Quality” and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.

Image-Guided Stereotactic Radiosurgery for the Treatment of Spasticity and Pain: A Preliminary Experience.

BackgroundSpasticity is a major health problem worldwide. Response to current medical and rehabilitation treatments is often poor. Surgical treatment is available only for a very limited number of patients.AimWe recently reported the application of stereotactic radiosurgery as a treatment option for spasticity and related pain. This paper describes a larger experience using image-guided stereotactic radiosurgery targeting the cervical or lumbar spinal roots to relieve spasticity and pain in four patients.MethodsAll the patients had refractory spasticity and related pain, one patient had additional paroxystic neuralgic pain. The cause of spasticity and pain was a traumatic brain and/or spinal cord injury, brain and/or spinal cord surgery, and stroke. Symptoms affected the right superior limb in one patient, and the inferior limbs in three patients (unilaterally in two, bilaterally in one). According to the symptoms, one patient was treated at the cervical level (C7 right sensory root) and three patients at lumbar level (right L4, left S1, and L2 roots bilaterally). The target was selected on constructive interference in steady-state (CISS) MR, focusing the irradiation on the postganglionic sensory segment of the cervical root or the intra-foraminal dorsolateral sensory portion of the lumbar roots. Appropriate spasticity and pain scales were used to assess the patient’s status after the treatment.ResultsThe treatments were tolerated well. Marked symptomatic relief was found in all the treated patients. Improvements in spasticity and pain scales were observed up to the latest follow-up. After 2 years, the mean reduction of the visual analog scale (VAS) and Modified Ashworth Scale (MAS) was 64.3% and 43.7%, respectively, while the median reduction of MAS score was 50%.ConclusionsExcept for a previous case report, this is the first study describing a novel noninvasive technique based on image-guided radiosurgery to treat severe spasticity and pain due to brain and spinal cord injury. This novel technique appears to be safe and effective and deserves to be studied further.

Anterior Spinal Cord Ischemia due to an Acute Aortic Intramural Type B Hematoma

Anterior Spinal Cord Ischemia due to an Acute Aortic Intramural Type B Hematoma

Subepicardial burn injuries in bullfrog heart induce electrocardiogram changes mimicking inferior wall myocardial infarction.

Using bullfrog hearts, we previously reproduced a ST segment elevation in electrocardiogram (ECG), mimicking human ischemic heart disease. In the present study, by inducing subepicardial burn injuries on the inferior part of the frog heart ventricle, we could reproduce typical ECG changes observed in human inferior wall myocardial infarction, such as the marked elevation of the ST segments in inferior limb leads (II, III, aVF) and their reciprocal depression in the opposite limb leads (I, aVL). Due to the decrease in Na+/K+-ATPase protein expression, the resting membrane potential of injured cardiomyocytes shifted toward depolarization. Such induced electrical difference between the injured and intact cardiomyocytes was thought to be responsible for the creation of “currents of injury” and the subsequent ST segment changes.

Deep Vein Thrombosis and Diabetes Mellitus Type 2 as Complications of Psoriatic Arthritis: A Case Report

A woman, 45 years old, complained of low back pain that improves with activity or analgesic andreoccurs when resting. The patient also complained of swollen joints, fever, shortness of breath, flakyskin and fragile nails. Physical examination found multiple inflamed joints, thickened and fragilenails, fever, limited range of movement of knee and ankle and positive Homan sign. Workup foundnegative anti-rheumatoid factor, increased blood sugar level, increased erythrocyte sedimentation rate,increased C-reactive protein, bacteria in urine, increased D-dimer, and imaging of lumbar spondylosisand sacroiliitis, and deep vein thrombosis in the left inferior limb using Doppler ultrasonography. Thepatient was diagnosed as psoriatic arthritis, deep vein thrombosis, type 2 diabetes mellitus, and urinarytract infection. The patient was given sulfasalazin, fondaparinux, warfarin, insulin, and antibiotic. Onthe 15th day of treatment, the patient experienced sudden shortness of breath and chest pain. The patientdied due to suspected cardiovascular event.

Chronic itch induced by thalamic deep brain stimulation: a case for a central itch centre

BackgroundCentral itch syndrome has been previously described in conditions such as stroke. The neurophysiology of central itch syndrome has been investigated in non-human primates but remains incompletely understood.MethodsWe report an observational study of a rare case of severe central itch following thalamic deep brain stimulation and postulate the location of the central itch centre in humans.ResultsThe patient was a 47-year-old female, with congenital spinal malformations, multiple previous corrective spinal surgeries and a 30-year history of refractory neuropathic pain in her back and inferior limbs. Following multidisciplinary pain assessment and recommendation, she was referred for spinal cord stimulation, but the procedure failed technically due to scarring related to her multiple previous spinal surgeries. She was therefore referred to our centre and underwent bilateral deep brain stimulation (DBS) of the ventral posterolateral nucleus of the thalamus for management of her chronic pain. Four weeks after switching on the stimulation, the patient reported significant improvement in her pain but developed a full body progressive itch which was then complicated with a rash. Common causes of skin eczema were ruled out by multiple formal dermatological evaluation. A trial of unilateral “off stimulation” was performed showing improvement of the itchy rash. Standard and normalized brain atlases were used to localize the active stimulating contact within the thalamus at a location we postulate as the central itch centre.ConclusionsPrecise stereotactic imaging points to the lateral portion of the ventral posterolateral and posteroinferior nuclei of the thalamus as critical in the neurophysiology of itch in humans.

How I do it: horizontal fissure approach to the middle cerebellar peduncle.

The horizontal fissure approach is a workhorse for brainstem lesions in the central and dorsolateral pons and middle cerebellar peduncle (MCP). The cerebellopontine fissure is a V-shaped fissure with a superior and inferior limb between the cerebellum, pons, and MCP. The horizontal or petrosal fissure is at the apex of the cerebellopontine fissure and extends laterally to divide the petrosal surface of the cerebellum into superior and inferior parts. Splitting this fissure exposes the posterolateral aspect of the MCP without excessive retraction or transgression of the cerebellum. We demonstrate and describe the horizontal fissure operative approach to the middle cerebellar peduncle for resection of a pontine cavernoma with illustrative figures and operative video. Splitting the horizontal (petrosal) fissure of the cerebellum brings the middle cerebellar peduncle into view behind the root entry zone of the trigeminal nerve, providing an expanded, safe corridor to the central and dorsolateral pons.

Prognostic effect of peripheral vascular disease in patients undergoing coronary artery bypass graft surgery

Abstract Introduction Atherosclerosis vascular disease is one of the main causes of morbidity and mortality in the world. We aimed to evaluate the prognostic impact of a history of peripheral vascular disease in patients undergoing coronary artery bypass graft surgery (CABG). Methods Single-center, observational and retrospective study including all patients undergoing CABG in our center between 2010 and 2018. Electronic health records were used to record clinical characteristics to identify patients with a history of peripheral vascular disease. This one was defined as having a history of stroke or transient ischemic attack (TIA), intermittent claudication, or previous percutaneous or surgical arterial procedure. Patients were followed until December 2019. The primary endpoint (PE) was the composite of stroke, TIA, myocardial infarction, new coronary revascularization, inferior limb vascular or aortic aneurysm intervention, and death. Results We included 567 patients, 138 (24.3%) with a history of peripheral vascular disease (stroke/TIA 34.1%; carotid surgery 6.5%; inferior limb surgery 12.3%; abdominal aortic aneurysm surgery 8.7% and intermittent claudication 38.4%). Baseline characteristics of the overall cohort and different subgroups (with and without peripheral vascular disease) can be seen in the table. The group with peripheral vascular disease had a worse clinical profile. They were significantly older, more frequently males, and smokers. They also had a higher prevalence of hypertension, diabetes, dyslipidemia, chronic kidney disease, and neoplasms. In addition, the preoperative status was less favorable, left ventricular ejection fraction and hemoglobin were lower, and renal function was worse than the group without peripheral vascular disease. The median follow-up was 4.2 years. During the study period, 55 patients (40%) with peripheral vascular disease and 80 patients (18.6%) without peripheral vascular disease reached the PE. After multivariate Cox modeling, variables independently related to PE were diabetes (HR=1.65 (1.17–2.33); p=0.004), creatinine levels (HR= 1.32 (1.19–1.47); p≤0.001) and peripheral vascular disease (HR= 2.28 (1.60–3.25); p≤0.001) (figure, panel A). Kaplan-Meier survival curves of PE according to the presence of peripheral vascular disease prior to CABG are shown in panel B of the figure. Conclusion According to our results, patients with peripheral vascular disease have approximately double the risk of suffering a major complication after CABG. Larger studies are needed to confirm these results. Funding Acknowledgement Type of funding sources: None. Description of studied population.HR and Kaplan-Meier curves

Applicability of a sheep model for training in plastic surgery of eyelids and orbit.

To test the applicability of a fresh tissue model for teaching facial plastic techniques and approaches to the eyelids and orbit. Observational animal experiments. Ten prepubescent sheep heads harvested following humane euthanasia at the completion of unrelated live animal research. Young sheep were saline perfused at the end of an in vivo protocol. Head and neck tissues were harvested and refrigerated for 3-7days. An experienced oculoplastic surgeon and an otolaryngologist explored the feasibility of common oculoplastic procedures in the ovine model. The model has potential for teaching basic principles in eyelid surgery including upper lid blepharoplasty, aponeurotic ptosis repair, upper lid gold weight lid loading for facial paralysis, lateral canthotomy and inferior limb cantholysis, lower lid tightening, and transconjunctival approach to the orbital floor. Eye muscle advancement, optic nerve sheath fenestration, and enucleation also accurately simulated human surgery. Anatomic variations limit the sheep model for orbital floor reconstruction and lacrimal drainage procedures. The sheep head and neck provide an inexpensive, safe model for developing skills in several oculoplastic procedures. Formal simulation testing is needed to confirm these expert opinions.

Building a continuous passive mobilization machine (CPM) for the inferior limb recuperation

This paper is presenting the projection and realization of a passive mobilization device (CPM), used for rehabilitate lower knee articulation conditions, such as post-traumatic conditions, degenerative, ligamento-plastic chirurgical interventions, meniscectomy and in special patients who have had been under knee prosthesis chirurgical interventions, this one being the one which causes the biggest issues in the rehabilitation process. Also, in this paper are figured the main steps which are followed throughout the building process of a Low-Cost functional prototype and its way of function.

Orthoplastic reconstruction in children: are the risk factors similar to those observed in adults?

Free flaps in the pediatric population are less common and when indicated the expectations to avoid amputation are high. The objective of this study is to describe indications and results of free flaps for limb reconstruction. Patients undergoing microsurgical free flaps in an orthopedic hospital were consecutively included in this cross-sectional study, from 2014 to 2020. Data regarding personal medical history, intraoperative microsurgical procedure and laboratory tests were collected. Patients under 18 years of age were included. Complications and free flap outcomes were observed during follow-up. This study included 23 free flaps in 23 patients with orthoplastic reconstruction. The free flap was performed as a reconstructive elevator concept. The most common indications were skin or bone defects caused by trauma (nine patients), tumor (six patients) and congenital pseudarthrosis of the tibia (four patients). The most indicated flap was a vascularized fibular flap in 10 patients, followed by an anterolateral thigh flap in 5 patients. Complications were observed in five patients. In total 93% of patients with inferior limb reconstruction walked at the final evaluation. Among risk factors studied, cases had a higher incidence of complications (P = 0.03) when only the superficial venous system was used. Free flaps in children are well-tolerated and indications are restricted to precise indications to provide alternatives to amputations and improve patient's function. We observed an increase in the incidence of complications when only superficial veins were used for free flap outflow in children.

A Prospective Study of Intraarterial Infusion Chemotherapy in Advanced Wild-Type BRAF Melanoma Patients

Treatment strategies for advanced cutaneous melanoma (CM) patients, resistant or not treatable with novel target and immunotherapeutic drugs, remain a significant challenge, particularly for patients with unresectable stage IIIC/D disease localized to inferior limbs and pelvis, for whom specific outcomes are rarely considered. This is a prospective study of multidisciplinary treatments, including locoregional melphalan chemotherapy, in 62 BRAF wild-type CM patients with locoregional metastases in the inferior limbs and pelvis, including inguinal regions. Patients were either in progression following or ineligible for, or not treatable with novel immunotherapy. For exclusively inferior limb-localised disease, patients received locoregional melphalan chemotherapy performed by hyperthermic isolated limb perfusion (n=19) or isolated limb infusion (n=19), and for synchronous lesions localised to inferior limbs and pelvis, received hypoxic pelvic and limb perfusion (n=24). Additional multidisciplinary therapy included local, locoregional and systemic treatments and the primary endpoint was tumour response. The objective response rate following first cycle of locoregional chemotherapy was 37.1% at 3 mo and median progression-free survival was 4-mo, with 12.9% procedure-related complications, 30.6% low-grade haematological toxicity and 11.3% severe limb toxic tissue reactions. Multivariate logistic regression showed that the odds of response were significantly higher for patients ≤ 75 y of age and for patients with locoregional metastases exclusively located in the inferior limbs. In this subgroup of CM patients with BRAF wild-type status, locoregional metastases localized to inferior limbs and pelvis, in progression following or ineligible for immunotherapy, melphalan locoregional chemotherapy demonstrated a safe and effective profile. ClinicalTrials.gov Identifier NCT01920516; date of trial registration: August 6, 2013.

Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure

BackgroundAtrial arrhythmias are well-known complications of atrial septal defect (ASD), and associated with substantial morbidity. After ASD closure, right atrial and ventricular enlargement regresses, however, the risk of atrial arrhythmia development continues. In this study, we aimed to investigate the relationship between the Crochetage sign, which is a possible reflection of heterogeneous ventricular depolarization due to long-term hemodynamic overload, and the development of late atrial arrhythmia after ASD closure. MethodsThis retrospective study included a total of 314 patients (mean age: 39.5 (30–50) years; male: 115) who underwent percutaneous device closure for secundum ASD. The study population was divided into two groups according to the presence or absence of the Crochetage sign. The Crochetage sign was defined as an M-shaped or bifid pattern notch on the R wave in one or more inferior limb leads. Cox-regression analysis was performed to determine independent predictors of late atrial arrhythmia development. ResultFifty-seven patients (18.1%) presented with late atrial arrhythmia. Of these 57 patients, 30 developed new-onset atrial fibrillation/atrial flutter (AF/AFL), and 27 patients with pre-procedure paroxysmal AF/AFL had a recurrence of AF/AFL during follow-up. History of paroxysmal AF/AFL before the procedure (HR: 4.78; 95% CI 2,52–9.05; p < 0.001), the presence of Crochetage sign (HR: 3.90; 95% CI 2.05–7.76; p < 0.001), and older age at the time of ASD closure (HR: 1.03; 95% CI 1.01–1.06; p = 0.002) were found as independent predictors for late atrial arrhythmia. ConclusionThe presence of Crochetage sign may be used to predict the risk of late atrial arrhythmia development after transcatheter ASD closure.

Temporal lobe epilepsy: A never-ending story

IntroductionSemiology and anatomo-electroclinical correlations remain invaluable for maintaining the level of excellence in temporal lobe epilepsy (TLE) surgery, in parallel to the constantly evolving technical progress. The aim of this study was to address semiological frequent and not so frequent signs, rarities and red flags in a long follow-up surgical series of patients suffering from TLE. MethodsPatients operated within the boundaries of the TL at our center, with presurgical video-EEG recorded seizures and seizure free after a postoperative follow-up of at least 24 months were included. Ictal semiology was systematically described and new red flags were explored by comparing with a second group of patients with the same inclusion criteria but whose outcome had been unfavorable (Engel II-IV). ResultsSixty-two patients were included, 46 seizure free and 16 with outcome Engel II-IV. Most seizure-free patients had a classical semiological presentation including aura (69.6%, abdominal the most frequent), followed by loss of responsiveness (90.2%) oral automatisms (90.7%), ipsilateral gestural automatisms (53.5%), contralateral upper limb dystonia (37.5%) or immobility (39.1%), and early ipsilateral non-versive head orientation (33.3%). More infrequent presentations were also present in the group of seizure-free patients: ictal language disturbance (13%), maintenance of responsiveness during seizures (9.8%), and contralateral rhythmic non manipulative automatism (6.9%). The presence of an isolated viscerosensory and/or psychic aura was significantly more frequent in the seizure-free group (p = 0.017), as well as oroalimentary automatisms (p = 0.005). Two signs were only present in the group with outcome Engel II-IV, constituting possible red flags (0.06 < p < 0.07): inferior limbs stepping-like automatisms and postictal dysarthria. ConclusionAn adequate clinical exam during seizures and a careful analysis of video recordings allow to recognize infrequent but well-characterized ictal signs that are part of the range of semiology in TLE, together with the most frequent and classical ictal presentations. Special attention to the localization hypothesis must be paid in the absence of oroalimentary automatisms or when the signs classified as possible red flags emerge.

COVID-19 Changed the Incidence and the Pattern of Pediatric Traumas: A Single-Centre Study in a Pediatric Emergency Department

The first wave of COVID-19 spread worldwide from March to May 2020. Italy was one of the countries in the world where the lockdown period was most prolonged and restrictive. To date, the impact of prolonged lockdown on pediatric traumas has not fully investigated. This paper aimed to analyze, and compare to 2019, the incidence and the fracture pattern in patients admitted to our pediatric hospital during the total lockdown period. A single-center retrospective study was performed. The data were gathered from the Pediatric Emergency Department (PED) of the Bambino Gesù Children Hospital of Rome (Palidoro). This PED is the pediatric referral center for Rome and the hub for pediatric traumas of the region. Any admission diagnosis for fracture, trauma, sprains and dislocation during the lockdown period (10 March–4 May) were included. The demographic data, diagnosis, type of treatment, fracture segment, bone involvement and time interval between trauma and presentation to the PED were recorded. In 2020, a reduction of total traumas and fractures, compared to 2019 (p < 0.001), occurred (81%). Superior limb and inferior limb fractures decreased in 2020 compared to 2019 (p < 0.05). The identification of pediatric traumas and fractures trend could be useful to reorganize the PED. Epidemiological data from the previous lockdown could be helpful to prepare the healthcare system for new pandemic waves. Moreover, sharing national statistics and correlating those to other countries’ protocols, could be helpful to solve problems in case of worldwide emergency situations.

3 Years Expeimental Study on Abdominal Aortic Aneurysm Patients Who were Treated with Endovascular Aneurysm Repair at Dr. Mohammad Hoesin Hospital Palembang During 1st of January 2018 – 31st of December 2020

Abdominal aortic aneurysm (AAA) is a focal dilatation of the aortic segment with an increase of 1.5 times the normal value or ≥3 cm. The risk increases in old age and requires alternative surgery such as EVAR. EVAR is more useful in AAA therapy than surgery with wide incisions. This research was descriptive in RSMH Palembang for 5 years in 1st of January 2018 - 31st of December 2020 with variables of patient clinical characteristics and patient CTA results.&#x0D; The results showed that AAA was more common in men, aged 60-69 years with high school education, risk factors such as a history of CHF, hypertension, CAD, and smoking habits. Angiographic CT result showed proximal diameter &gt; 2 cm, PAU, calcification, iliac aneurysm, and lowest renal artery on the left side. All AAA patients had inferior limb thrombus and angulation &gt; 600. The average of aneurysm is 5.8 cm in diameter and 9.23 cm in length. The mean diameter of the right iliac artery differs from the mean diameter of the left iliac artery. The diameter of the right femoral artery also differs from the diameter of the left femoral artery. AAA patients mostly had no history of CKD, COPD, and DM. The patients were hospitalized for an average of 7 days, especially in the ICU for 2 days.

Thoracic spine schwannoma presenting with traumatic spinal cord injury: A case report

Background: The presentation of a thoracic spinal tumor due to high-impact trauma is quite rare and we found no other case reported.Case Description: This is a case report and literature review. A patient presented with severe paraparesis on day 4 after trauma. Thoracic MRI showed an oval image centered to T4-T5 suggestive of hemorrhage. The patient underwent a bilateral T4 and T5 laminectomy and microsurgically assisted intradural exploration. After laminectomy, we found no extradural lesions, so we proceeded to dural opening, after which we found a large extramedullary lesion which was completely removed. Pathology revealed a schwannoma. The patient had a very good recovery after surgery and motor rehabilitation. At 6 months after surgery, inferior limbs muscle strength was completely normal. We found no other case reported.Conclusion: Thoracic spine schwannomas are difficult to early diagnose unless there is a clinical suspicion. Initial presentation as bleeding after trauma was not described before. This presentation should be kept in the differential diagnosis of any patient with an acute neurological deficit without trauma signs on admission imaging.