Initial Neurological Examination Research Articles

Initial Neurologic Examination Does Not Determine Survival in Patients With Brain Metastases

was reported in 30% of patients with only three patients (43%) requiring narcotics or short-course steroids. There was no evidence of vertebral body fracture in any patient that achieved local control in the treated area. Conclusion: Spine stereotactic radiosurgery for thyroid metastases as a primary or adjuvant/salvage therapy is well-tolerated and yields high rates of local control. To our knowledge, this is the first study focusing on this modality for metastatic thyroid cancer patients only. Author Disclosure: M.B. Bernstein: None. E.L. Chang: None. B. Amini: None. M. Cabanillas: None. X. Wang: None. P.K. Allen: None. L. Rhines: None. C.E. Tatsui: None. P.D. Brown: None. A.J. Ghia: None.

Childhood acquired brain injury and subsequent delinquent behavior: A retrospective study of demographic, injury-related, neurological and cognitive characteristics in a sample of 40 patients

Childhood acquired brain injury (ABI) is responsible for severe cognitive and behavioural disorders, sometimes leading to violent and/or offending behaviours. The aim of this study was to review the cases of patients treated in a rehabilitation unit dedicated to children with ABI, who subsequently demonstrated behaviors leading to an intervention of the police and/or the justice, and identify any common characteristics. Retrospective inventory of patients with ABI treated in a single rehabilitation department, who subsequently had contact with the police/justice following offenses. We collected demographic factors, type and severity of ABI, initial neurological examination, first and last neuropsychological assessment, type of schooling pre- and post-injury, and data from their offenses. Searches retrieved 40 patients (36 boys): 34 traumatic brain injury (TBI; 27 severe), 4 brain tumours, 1 frontal hemorrhagic stroke and 1 anoxia; mean age at injury was 9.7 years [SD = 4; (2.1–15.7)]. In 88% of cases, none of the parents had graduated from high school. Half of the children had previous school difficulties and 30% had repeated a grade. Overall, children sustained severe injuries, with impaired neurological function, major cognitive deficits [mean initial full-scale IQ 73.1 (SD = 12.8)] without significant improvement [77.4 (SD = 13.4) at the last assessment]. The processing speed index was particularly low [73.2 (±15.4)] and did not improve over time. 76% had behavioural disorders already evident during hospitalization. Upon discharge, 62% required adapted and/or specialized schooling. After an average follow-up of 8 and a half years, only 6 patients still followed an ordinary curriculum and 8 were not attending school anymore. Four girls were victims, and among 36 boys, all were perpetrators, but 3 had been victims previously. The offenses were mainly cases of violence (56%), but also entailed thefts, traffic offences, sexual assaults, drug use and vandalism. Children with ABI who suffer or commit offenses are mainly boys, from very low socioeconomic background, with pre-injury academic and social difficulties, who sustained severe TBI. They suffer very severe and disabling cognitive deficits and behavioral disorders. Multidisciplinary care and follow-up of those children more at risk is essential in the long-term.

Combination of initial neurologic examination and continuous EEG to predict survival after cardiac arrest

BackgroundPrognosticating outcome following cardiac arrest requires a multimodal approach. We tested whether the combination of initial neurologic examination combined with continuous EEG was superior to either test alone for predicting survival after cardiac arrest. MethodsReview of consecutive patients receiving continuous EEG monitoring between April 2010 and June 2013. Initial neurologic examination was evaluated using the Full Outline of UnResponsiveness (FOUR) score and organ system dysfunction determined using the SOFA score. We defined four categories of initial post-cardiac arrest illness severity (PCAC): (I) awake, (II) coma (not following commands but intact brainstem responses)+mild cardiopulmonary dysfunction (SOFA cardiac+respiratory score <4), (III) coma+moderate-severe cardiopulmonary dysfunction (SOFA cardiac+respiratory score ≥4), and (IV) coma without brainstem reflexes. A second analysis focusing on neurologic injury divided subjects into three groups according to initial FOUR_B score; FOUR_B=0–1, FOUR_B=2 and FOUR_B=4. A blinded rater dichotomized continuous EEG patterns during the first 48h into malignant patterns (non-convulsive status epilepticus, convulsive status epilepticus, myoclonic status epilepticus and generalized periodic epileptiform discharges). The primary outcome was survival to hospital discharge. ResultsOf 331 subjects, mean age was 58 (SD 17) years and 206 (62.2%) subjects were male. Ventricular fibrillation or tachycardia (VF/VT) was the initial rhythm for 93 (28.1%) subjects. Among subjects with malignant cEEG, survival to hospital discharge rate was 0% for FOUR_B 0–1, 8.1% for FOUR_B 2 and 12.5% for FOUR_B 4, respectively. In one multivariate analysis, survival was independently associated with VF/VT, FOUR_B of 2, FOUR_B of 4, and non-malignant cEEG. In a separate model, survival was associated with VF/VT, PCAC<4 and non-malignant cEEG. The AUCs of FOUR_B, cEEG and the combination of FOUR_B and cEEG are 0.740 (95% C.I. 0.684–0.797), 0.674 (95% C.I. 0.615–0.732) and 0.820 (95% C.I. 0.773–0.868) respectively. The AUCs of PCAC, cEEG and the combination of PCAC and cEEG are 0.779 (95% C.I. 0.721–0.838), 0.672 (95% C.I. 0.612–0.7321) and 0.846 (95% C.I. 0.798–0.894) respectively. ConclusionCombining the initial neurologic examination using either FOUR_B or PCAC, with cEEG was superior to any individual test for predicting survival after cardiac arrest. We caution against using these findings to speed prognostication until they are externally validated.

Superficial siderosis following spontaneous intracranial hypotension

A 33-year-old man presented in 2002 with an acute, severe, occipital headache associated with nausea and photophobia, causing him to collapse to the pavement; there was no persisting neurological impairment....

Penetrating Stab Injury of Spine; Diagnostic Value of Thin-Section Multislice Computed Tomography

Penetrating stab injuries of the spinal cord (PSISC) are extremely rare and typically associated with immediate neurological damages. However, some patients may represent with atypical and indistinct symptoms. Herein we report a case of atypical presentation of spinal canal penetration which was not detected in thorax computerized tomography (CT) scans performed in emergency room, but subsequently was revealed in thoracal CT and magnetic resonance imaging (MRI) scans. Initial neurological examination was normal except for the hypoesthesia in the right lower extremity. Surgical treatment was not performed since any foreign body or effusion consistent with hematoma and/or dural leak, or extrinsic cord compression was present. After administering a prophylactic tetanus shot and initiating a broad-spectrum antibiotic prophylaxis, patient was discharged with recommendations. On follow-up, he described that hypoesthesia was decreased, but still present at end of the first month of injury. To conclude, it is very important to scan the affected region with thin slice thickness-multislice CT or with MRI for proper diagnosis in patients with stab wounds presented with neurological symptoms.

APRAXIA AND ASSOCIATED FEATURES AT PRESENTATION IN DEMENTIA

Introduction Limb apraxias, associated with disruption to the parietal lobe, have been commonly observed in various dementia syndromes. Parietal impairment also produces a range of other symptoms, including deficits in reading, writing and arithmetic. Aim The aim of this study was to determine the profile of these features in Alzheimer9s disease (AD) and Fronto-temporal dementia (FTD) spectrum disorders, at initial clinical presentation. Method A total of 85 patients:10 posterior cortical atrophy (PCA), 8 logopenic aphasia (LPA), 17 AD, 13 behavioural variant FTD, 6 progressive non-fluent aphasia (PNFA), 6 semantic dementia (SD), and 25 patient with subjective memory impairment (SCI) were recruited from the Oxford Cognitive Disorders Clinic. Retrospective case note analysis of initial clinical interview and neurological examination was undertaken. Results The prevalence of limb apraxia was highest in AD, LPA and PCA, and in PNFA. AOS was only observed in PNFA, present in all but one patient. The presence of other parietal features was highest in the AD spectrum disorders. Discussion The results suggest that simple clinical examination for the presence of apraxia and associated left parietal features at initial presentation can assist in differential diagnosis of AD and FTD spectrum disorders that typically show overlapping features.

G.P.298: A case of bilateral neuralgic amyotrophy combined with phrenic nerve palsy

Acute bilateral brachial plexopathy or neuralgic amyotrophy is an uncommon disorder of an unknown etiology. Characteristic symptoms include acute shoulder pain followed by profound weakness of the upper extremities that usually involves C5–6 innervated muscles. Rarely, it is reported to involve lower cranial nerves or phrenic nerve. We describe a patient with bilateral neuralgic amyotrophy with phrenic nerve palsy that was proven by electrodiagnostic and pulmonary function studies. A 59-year-old man presented with acute pain in both shoulders followed by bilateral arm weakness after a strenuous hiking. He also complained of orthopnea and he could not sleep in supine position. Initial neurological examination showed no cranial nerve involvement. His motor examination showed bilateral shoulder abduction weakness of MRC grade 3, internal and external rotation of both arm showed weakness of MRC grade 4. The nerve conduction study showed bilateral upper trunk plexopathy that involved bilateral lateral antebrachial and axillary nerves. The needle electromyography study showed active denervation potentials in deltoid, supraspinatus, infraspinatus and teres minor muscles. His chest computed tomography showed elevation of the left diaphragm that was compatible with phrenic nerve palsy and follow up nerve conduction study on bilateral phrenic nerves also demonstrated a markedly decreased CMAP. He was finally diagnosed as bilateral neuralgic amyotrophy with phrenic nerve palsy and we treated him with steroid. His shoulder pain and orthopnea showed a significant improvement after two weeks but there was no motor improvement. Phrenic nerve involvement is a rare in neuralgic amyotrophy. These patients are usually confusing and diagnosed lately due to orthopnea. Neurologists should be aware of such disease, as early diagnosis and prompt treatment is detrimental in relieving pain that consequently result in a faster recovery from various neurologic deficits.

Medial temporal lobe atrophy in Alzheimer's disease/mild cognitive impairment with depression.

Depression is common in patients with Alzheimer's disease (AD) and mild cognitive impairment (MCI). Patients with depression have an earlier onset and rapid progression of cognitive decline. Medial temporal lobe atrophy (MTA) is common in AD and MCI, and some degree of atrophy is found in almost all patients. In the present study, an attempt was made to know if MTA is more common in patients with AD/MCI with depression than those without it. Patients reporting to the outpatient department of a neurology centre of a tertiary care hospital were recruited for the present study. After initial general physical and neurological examination, they were evaluated using National Institute of Neurological and Communicative Disorders and Stroke and Related Disorders Association criteria for diagnosis of AD. Clinical Dementia rating scale was used for the diagnosis of MCI. Cornell scale for depression in dementia (CSDD) was used. We found 20 cases with depression as per CSDD out of a sample of 37 patients (male:female = 30:7). There were 26 patients with AD and 11 with MCI. The mean age of all patients was 72.33 ± 6.45 years. The mean mini mental status examination score was 19.00 ± 6.73. The mean time since diagnosis was 4.19 ± 3.26 years. The mean Scheltens visual rating scale score for right MTA was 2.08 ± 0.95 and was 2.05 ± 0.94 for the left. Both scores did not differ statistically when analyzed using paired t-test (p > 0.05). However, difference in those with depression (2.36 ± 0.95) from those without depression (1.60 ± 0.74) was significant (p < 0.05). MTA scores were higher in those with AD/MCI with depression than those without it.

Late‐onset cerebellar abiotrophy in a Labrador Retriever

A 5-year-old female spayed Labrador Retriever was examined for a hindlimb gait abnormality. Initial neurological examination was consistent with vestibular dysfunction. Over the course of 1 year, signs progressed to reflect cerebellar ataxia, vertical nystagmus and delayed postural reactions in all limbs. At the initial examination, subjective evaluation of magnetic resonance imaging scan of the brain was considered normal. Repeat imaging at 1 year after initial examination revealed a reduction in the size of the cerebellum. Retrospectively, the size of the cerebellum on the initial MRI was small when assessed using an objective measurement algorithm. Postmortem histopathological evaluation of the brain showed diffuse degeneration of Purkinje cell neurones with secondary granule cell loss in the cerebellum, in addition to pigment inclusions in brainstem neurones. The clinical history and clinicopathological data are consistent with late-onset cerebellar abiotrophy, which has not previously been described in this breed.

APRAXIA AND ASSOCIATED FEATURES AT PRESENTATION IN DEMENTIA

Introduction Limb apraxias, associated with disruption to the parietal lobe, have been commonly observed in various dementia syndromes. Parietal impairment also produces a range of other symptoms, including deficits in reading, writing and arithmetic. Aim The aim of this study was to determine the profile of these features in Alzheimer9s disease (AD) and Fronto-temporal dementia (FTD) spectrum disorders, at initial clinical presentation. Method A total of 85 patients:10 posterior cortical atrophy (PCA), 8 logopenic aphasia (LPA), 17 AD, 13 behavioural variant FTD, 6 progressive non-fluent aphasia (PNFA), 6 semantic dementia (SD), and 25 patient with subjective memory impairment (SCI) were recruited from the Oxford Cognitive Disorders Clinic. Retrospective case note analysis of initial clinical interview and neurological examination was undertaken. Results The prevalence of limb apraxia was highest in AD, LPA and PCA, and in PNFA. AOS was only observed in PNFA, present in all but one patient. The presence of other parietal features was highest in the AD spectrum disorders. Discussion The results suggest that simple clinical examination for the presence of apraxia and associated left parietal features at initial presentation can assist in differential diagnosis of AD and FTD spectrum disorders that typically show overlapping features.

Risk-adjusted outcome prediction with initial post-cardiac arrest illness severity: Implications for cardiac arrest survivors being considered for early invasive strategy

BackgroundEarly CATH is recommended for cardiac arrest survivors with STEMI or suspicion for coronary ischemia. Comatose patients are at risk of death from neurologic injury irrespective of CATH, but post-procedural mortality data do not distinguish between causes of death. Pittsburgh Post Cardiac Arrest Category (PCAC) is a validated, early post-cardiac arrest illness severity score based on initial cardiopulmonary dysfunction and neurologic examination. We evaluated the association between early coronary angiography (CATH) and patient outcome after adjusting for initial post-cardiac arrest illness severity. MethodsRetrospective study of a prospective cardiac arrest database at a single site. We included 1011 adult survivors of non-traumatic in-hospital or out-of-hospital cardiac arrest from 2005 to 2012, then stratified by PCAC and immediate CATH. Logistic regression tested the association between immediate CATH and patient outcomes, adjusting for PCAC. ResultsOverall, 273 (27%) received immediate CATH. Patients with immediate CATH had higher proportions of good outcome in all but the most severe stratum of illness severity (11% vs. 6%; p=0.11). The primary mode of death was neurologic for all but the least severe stratum. Adjusting for PCAC, immediate CATH was associated with favorable discharge disposition (OR 1.92; 95%CI 1.20, 3.07; p=0.006) and modified Rankin scale (OR 1.95; 95%CI 1.12, 3.38; p=0.02). ConclusionsThe benefit of CATH is less clear in the most severe stratum of illness, in which the high risk of mortality is primarily from neurologic causes. PCAC is a risk-stratification tool that provides pre-procedural risk-adjusted outcome prediction for post-cardiac arrest patients being evaluated for immediate CATH.

Childhood Stroke: Results of 130 Children From a Reference Center in Central Anatolia, Turkey

BackgroundAlthough stroke among children is rare, it can cause significant morbidity and mortality. We aim to share our experience of children with arterial ischemic stroke. MethodsThe initial symptoms, demographical features, risk factors, neurological examination, neuroradiological findings, and clinical follow-up data of 130 Turkish children seen between 2002 and 2013 were retrospectively analyzed. ResultsSixty-eight patients were male. Thirty of the children were aged from 1 to 12 months (seven of them died in this period). Focal neurological signs were the most common presentation, and hemiplegia or hemiparesis were the most common focal signs. Underlying risk factors were detected in 103 patients. Infections and congenital heart disease were the most common risk factors. Seven of the nine children with recurrent arterial ischemic strokes had one or more underlying diseases (moyamoya disease in two children along with factor V Leiden mutation, tuberculous meningitis, congenital heart disease, homocystinuria, and hemiconvulsion-hemiplegia-epilepsy syndrome). The arterial ischemic stroke was located in the middle cerebral circulation in 68 (36 left and 32 right) and in the posterior cerebral artery in 41. Eighteen children died. The neurological outcome was assessed in 98 children. Of these children, 66 children have neurological deficits and 52 children have seizures. Stroke in the first year of life is more often fatal. Recurrent stroke is associated with poor prognosis. ConclusionTuberculous meningitis is still a risk factor for arterial ischemic stroke in Turkey. Arterial ischemic stroke in the first year of life and recurrent arterial ischemic stroke represent poor prognostic features.

A case of delayed neurological recovery with luxury perfusion and a high intracranial arterial calcification burden.

Dear Sir, Although patients with acute ischemic stroke achieve recanalization, approximately 37%-65% of them do not show immediate improvement.1 The term stunned brain refers to delayed neurological recovery after an ischemic insult to the brain.1 We describe the case of a patient with delayed neurological recovery who had a small cerebral infarction but relatively rapid compensatory perfusion and high calcification burden in the intracranial arteries. A 71-year-old woman visited our emergency room 1.5 hours after developing acute right limb weakness. The initial neurological examination revealed right hemiplegia (arm and leg, grade 2 on the Medical Research Council grading system) and global aphasia (National Institutes of Health Stroke Scale score, 22). Non-enhanced computed tomography did not reveal a definite ischemic or hemorrhagic lesion, and intravenous recombinant tissue plasminogen activator was subsequently infused. Computed tomography angiography revealed a moderate degree of stenosis in the left middle cerebral artery (Figure 1A) and a high calcification burden in almost all intracranial arteries (Figure 1A, B). We assumed that an occlusion of the middle cerebral artery might be in the process of recanalization. Immediate magnetic resonance imaging revealed a small acute infarction near the posterior pole of the lateral ventricle on diffusion-weighted imaging (Figure 1C). Perfusion magnetic resonance imaging performed simultaneously revealed luxury perfusion in the left posterior temporo-parieto-occipital area (Figure 1D). Although her neurological symptoms had improved 24 hours after onset, she still had right hemiparesis (arm and leg, grade 4) and dense sensory aphasia (National Institutes of Health Stroke Scale score, 8). The localization of these neurological deficits corresponded to the area of luxury perfusion. On the fourth day after admission, the small lesion persisted on diffusion-weighted imaging (Figure 1E), and the luxury perfusion had normalized (Figure 1F), but the neurological deficits including sensory aphasia remained (National Institutes of Health Stroke Scale score, 7). By the sixth day after admission, her neurological deficits had completely disappeared. Figure 1 Initial computed tomography (CT) and magnetic resonance (MR) images of the patient in this study. (A) A coronal maximum intensity projection image from CT angiography shows significant stenosis of the distal left middle cerebral artery, which was lined ... The patient showed some immediate neurological recovery, but sensory aphasia persisted even though the diffusion-restricted lesion was small and the cerebral perfusion pattern was compensatory. We propose that this delayed neurological recovery was associated with vascular aging, which was reflected by the high intracranial arterial calcification burden. Calcium deposition in the vasculature is one of the main components of vascular aging,2 which is associated with poor adaptation following ischemia/reperfusion injuries.3 In addition, neovascularization following reperfusion is hampered by the vascular calcification process.4 Reperfusion may result in increased levels of reactive oxygen species that subsequently impair endothelial progenitor cell function.5 With regard to post-stroke repair mechanisms, endothelial progenitor cells are known to be essential for neovascularization.6,7 The delayed neurological recovery could be explained by these poor adaptations and hampered neovascularization following revascularization. The delayed neurological recovery in this patient could also have been associated with the luxury perfusion phenomenon; however, a previous report has shown a relationship with perfusion deficit. Hyperperfusion on perfusion magnetic resonance imaging is thought to reflect a high degree of ischemic stress.8 The hyperperfused area was reported to correspond to the area of cerebral infarction in this patient. When compared to patients with normal perfusion, those with hyperperfusion show lower apparent diffusion coefficient values.8 Moreover, delayed clinical recovery has been reported to be associated with perfusion deficits.1 A defect that extends beyond a diffusion-restricted area is referred to as an ischemic penumbra,9 which exhibits deranged cerebral metabolism and can be identified using perfusion imaging. The present case indicates that either hyperperfusion or hypoperfusion may be associated with delayed neurological recovery after cerebral arterial recanalization.8 In conclusion, the delayed neurological recovery observed in our patient might have resulted from either post-ischemic reperfusion syndrome associated with luxury perfusion, or an impaired post-stroke repair mechanism associated with a high burden of intracranial arterial calcification. Computed tomography and magnetic resonance imaging are both useful for estimating the degree of ischemic injury.

Junger Patient mit akuter einseitiger Amaurose

A 39-year-old patient presented with acute visual loss of the left eye. Although the initial ophthalmological and neurological examinations were uneventful, magnetic resonance imaging (MRI) showed optic canal narrowing and compression of the optic nerve secondary to a prominent posteriorly misplaced ethmoidal cell (so-called Onodi cell). Endonasal ethmoidectomy with decompression of the infected Onodi cell was performed. Microbiological testing showed growth of Haemophilus influenzae. Despite early surgical intervention vision could not be restored.

Femoral Nerve Injury Due to an Open Subtrochanteric Hip Fracture – The Importance of Early Detection and Implication for Rehabilitation

Purpose: Here we present the unusual case report of where a woman sustained a traumatic injury causing an open right subtrochanteric hip fracture which damaged the femoral nerve. Case Report: A 39-year old woman presented with an open right subtrochanteric hip fracture following an accident at work where a large heavy pallet fell onto her causing both hips to hyperextend. She sustained 10 cm transverse wound near the groin crease and the proximal end of the shaft of the femur was visible in the wound. Initial neurological examination was limited by the fracture and associated pain but it was noted that she had decreased sensation to light touch in the distribution of the femoral nerve. She was taken to theatre that day and underwent debridement with exploration of the right groin and fracture fixation with a femoral nail. She recovered well post-operatively though was noted to have patchy numbness over the leg in a non-dermatomal pattern. Subsequent EMG examination demonstrated a near complete lesion to the right femoral nerve to quadriceps. She continued physiotherapy and gradually improved but three years after the injury she still struggles with her gait because of reduced hip flexion power and restricted knee flexion.

Late ventriculo-atrial shunt migration leading to pericardial cerebrospinal fluid effusion and cardiac tamponade

We present the case of a patient with cardiac tamponade secondary to late intrapericardial migration of a disrupted ventriculo-atrial shunt (VAS). A 48-year old woman was referred for cardiac tamponade. She had a history of congenital hydrocephalus with implantation of a VAS (Codman(®)) in 1994. The initial neurological examination was normal. Tomodensitometry showed a discontinuity of the VAS at the cervical level with its distal part floating in the pericardium. Immediate surgery through sternotomy allowed the draining of the pressurized translucid liquid. The distal part of the VAS was extracted and the perforation site on the right ventricle was sutured. The patient showed no neurological trouble 3 months after operation. Surprisingly, cardiac tamponade was not related to bleeding but to the accumulation of translucid liquid whose gross aspect and biochemistry were very suggestive of cerebrospinal fluid (CSF). We hypothesize that a fibrin sheath had developed around the VAS at the time of its disconnection and acted as a fibrous tunnel allowing continued CSF drainage through its distal part. Surgical strategies to prevent late VAS disconnection should be considered at the time of implantation.

Posterior Reversible Leukoencephalopathy Syndrome Presenting with Global Cerebral Edema and Herniation

We report a case of global cerebral edema and herniation due to Posterior Reversible Leukoencephalopathy Syndrome (PRES). Case report. A 37-year-old healthy female developed persistent severe occipital headache, and after 1 month of persistent headache, developed an episode of loss of consciousness. CT brain showed diffuse cerebral edema and effacement of the sulci and basal cisterns. Her initial neurological examination was nonfocal but with severe headache. Overnight, she acutely became unresponsive with fixed dilated pupils, tachycardia, and hypertension. She was intubated and treated with hypertonic saline and mannitol with improvement in her clinical status. Intracranial Pressure (ICP) monitor showed elevated ICPs to 37 mmHg which responded to mannitol. MRI brain showed diffuse vasogenic edema predominantly in the white matter without enhancement. Cerebral angiogram was unremarkable. Cerebrospinal fluid including infectious work-up was negative. With supportive care, her mental status improved. On her 3 month follow-up visit, she was asymptomatic and had returned to work. Repeat MRI brain at 3 months showed persistent white matter changes that subsequently resolved at 9 months. Although PRES is typically considered to have a benign clinical course, clinician should be aware that severe cases can present with global cerebral edema and associated complications including intracranial hypertension and herniation.

Abstract 66: Association of Initial Neurological Examination with Survival Following Out-of-Hospital Cardiac Arrest

Introduction: Following resuscitation from out-of-hospital cardiac arrest (OHCA), failure to awaken from coma remains a common cause for withdrawal of care. Prior investigations have demonstrated initial organ system dysfunction is associated with survival and neurologic outcome. Hypothesis: We hypothesized that initial neurologic examination would be associated with survival following resuscitation from cardiac arrest. Methods: We conducted a retrospective study of 111 comatose OCHA subjects treated with dedicated post-arrest protocols, including therapeutic hypothermia and hemodynamic optimization. These subjects were prospectively enrolled in a multicenter clinical study examining mitochondrial dysfunction from ischemia-reperfusion injury (COMICA Study Group). Subjects not receiving sedation during the initial examination were eligible for analysis. Neurologic examination was classified using the motor and brainstem subscores of the Full Outline of UnResponsiveness (FOUR). For analysis, subjects were dichotomized as deep coma (FOUR Motor+ Brainstem&lt;4) or not. Survival and good neurologic outcome, defined as a Cerebral Performance Category (CPC) of 1-2 and Modified Rankin Scale (mRS) of 0-3 were compared using chi-squared tests. Results: Mean age was 61 (SD 17) years, 66 (59%) male, witnessed in 91 (82%), and received bystander CPR in 49 (44%) of cases. The predominant rhythm was VF/VT in 56 (50%) and low flow time was 19 (IQR 9, 28) minutes. The initial neurologic examination was obtained without sedation in 54 (49%) of subjects. Subjects with deep coma on initial examination were less likely to survive (18% vs. 65%; p&lt;0.001), or have a good outcome using CPC (15% vs. 45%; p=0.01) or mRS (15% vs. 45%; p=0.01). Conclusions: Deep coma on initial neurologic examination is associated with death prior to discharge and poor neurologic outcome. However, depth of coma alone is insufficient to rule out good outcome.

Is progressive upper-body apraxia a corticobasal syndrome?

Corticobasal degeneration (CBD) is characterized by various clinical manifestations including corticobasal syndrome, progressive supranuclear palsy-like syndrome and frontotemporal dementia. Focal cortical atrophy syndrome as the initial manifestation rarely occurs in CBD. Here, we present a 62-year-old man and a 70-year-old man who were admitted due to clumsiness in the arms. On initial neurological examination, they showed asymmetric limb apraxia without parkinsonism or global cognitive dysfunction. Brain MRI showed focal atrophy in the frontal and prefrontal cortices, and brain positron emission tomography scan revealed decreased metabolism in these same brain locations. Although these patients developed parkinsonism and dystonia within several years, the neurological signs were limited to the arms for a long period. “Progressive upper-body apraxia” may be a rare clinical manifestation of CBD which shows a benign clinical outcome. The patients described may enhance our understanding of the clinical heterogeneity of this disease.

A 62-Year-Old Man With Fluctuating Neurological Deficits and Skin Lesions

A 62-year-old man with no significant medical history experienced fatigue, night sweats, hoarseness of voice, and dry cough, which were followed by vision disturbances in his left eye. He lost about 4.5 kg (10 lb) in just over a month. Three weeks later, he had difficulty recollecting his e-mail password and trouble with word finding. The next day, he experienced numbness in his left arm. He also developed a maculopapular and erythematous rash in the groin, genitalia, and buttocks. The results of an initial neurological examination were normal, including his higher mental functions. An initial blood workup revealed normocytic normochromic anemia. The results of cerebrospinal fluid studies were unremarkable. Magnetic resonance imaging of his brain at hospital admission revealed multifocal increased T2 signals in the subcortical white matter. A conventional cerebral angiogram was unremarkable. A biopsy specimen from the right frontal lobe revealed demyelination and perivascular lymphocytic infiltration. A provisional diagnosis of acute disseminated encephalomyelitis was made. In spite of steroid treatment and plasmapheresis, his clinical status deteriorated rapidly. The approach to the diagnosis of a rapidly progressive multifocal brain disorder is discussed.