Ipsilateral Symptoms Research Articles

Development and Validation of the Cluster Headache Screening Questionnaire.

Background and PurposeCluster headache (CH) is frequently either not diagnosed or the diagnosis is delayed. We addressed this issue by developing the self-administered Cluster Headache Screening Questionnaire (CHSQ).MethodsExperts selected items from the diagnostic criteria of CH and the characteristics of migraine. The questionnaire was administered to first-visit headache patients at nine headache clinics. The finally developed CHSQ included items based on the differences in responses between CH and non-CH patients, and the accuracy and reliability of the scoring model were assessed.ResultsForty-two patients with CH, 207 migraineurs, 73 with tension-type headache, and 18 with primary stabbing headache were enrolled. The CHSQ item were scored as follows: 3 points for ipsilateral eye symptoms, agitation, and duration; 2 points for clustering patterns; and 1 point for the male sex, unilateral pain, disability, ipsilateral nasal symptoms, and frequency. The total score of the CHSQ ranged from 0 to 16. The mean score was higher in patients with CH than in non-CH patients (12.9 vs. 3.4, p<0.001). At a cutoff score of >8 points, the CHSQ had a sensitivity, specificity, positive predictive value, and negative predictive value of 95.2%, 96%, 76.9%, and 99.3%, respectively.ConclusionsThe CHSQ is a reliable screening tool for the rapid identification of CH.

Safety of Early Carotid Artery Stenting for Symptomatic Stenosis in Daily Practice

In 2006, the American Heart Association recommended that for preference carotid endarterectomy (CEA) or, alternatively, carotid angioplasty and stenting (CAS) for symptomatic carotid artery stenosis should ideally occur within 14 days of an ischaemic event. The aim was to determine the safety of CAS according to those recommendations in daily practice. A retrospective analysis was performed of all consecutive patients (2000–16), with ipsilateral carotid symptoms who underwent CAS for extracranial carotid stenosis ≥70%, who were previously included in a prospective database. Thirty day morbidity was assessed (any stroke without transient ischaemic attack [TIA]/amaurosis fugax), along with mortality of the procedure in the early (≤14 days after stroke onset) and delayed phases (15–180 days after stroke onset). Patients who received CAS and/or mechanical thrombectomy for acute ischaemic stroke treatment were not included. In total, 1227 patients with symptomatic carotid stenosis who underwent CAS were identified. Early and delayed CAS was performed in 291 and 936 patients, respectively. Morbidity (any stroke) and mortality was 2.2% (n = 27) in the whole cohort (n = 8 [2.7%] in early vs. n = 19 [2%] in delayed CAS; p = .47). There were no differences in morbidity between early and delayed CAS regarding TIA (n = 15 vs. 36 [5.2% vs. 3.9%]; p = .33), minor stroke (n = 4 vs. 5 [1.4% vs. 0.5%]; p = .14), or major stroke (n = 2 vs. 6 [0.7% vs. 0.6%]; p = .59). Two patients (0.7%) died after early CAS and eight (0.9%) after delayed CAS (p = .56). CAS may be safely performed in the early phase after an ischaemic stroke with low clinical complication rates. Further studies are needed to validate CAS safety conducted even earlier in the acute phase of ischaemic stroke.

Safety of Early Carotid Artery Stenting for Symptomatic Stenosis in Daily Practice

In 2006, the American Heart Association recommended that for preference carotid endarterectomy (CEA) or, alternatively, carotid angioplasty and stenting (CAS) for symptomatic carotid artery stenosis should ideally occur within 14 days of an ischaemic event. The aim was to determine the safety of CAS according to those recommendations in daily practice. A retrospective analysis was performed of all consecutive patients (2000-16), with ipsilateral carotid symptoms who underwent CAS for extracranial carotid stenosis ≥70%, who were previously included in a prospective database. Thirty day morbidity was assessed (any stroke without transient ischaemic attack [TIA]/amaurosis fugax), along with mortality of the procedure in the early (≤14 days after stroke onset) and delayed phases (15-180 days after stroke onset). Patients who received CAS and/or mechanical thrombectomy for acute ischaemic stroke treatment were not included. In total, 1227 patients with symptomatic carotid stenosis who underwent CAS were identified. Early and delayed CAS was performed in 291 and 936 patients, respectively. Morbidity (any stroke) and mortality was 2.2% (n=27) in the whole cohort (n=8 [2.7%] in early vs. n=19 [2%] in delayed CAS; p=.47). There were no differences in morbidity between early and delayed CAS regarding TIA (n=15 vs. 36 [5.2% vs. 3.9%]; p=.33), minor stroke (n=4 vs. 5 [1.4% vs. 0.5%]; p=.14), or major stroke (n=2 vs. 6 [0.7% vs. 0.6%]; p=.59). Two patients (0.7%) died after early CAS and eight (0.9%) after delayed CAS (p=.56). CAS may be safely performed in the early phase after an ischaemic stroke with low clinical complication rates. Further studies are needed to validate CAS safety conducted even earlier in the acute phase of ischaemic stroke.

Early carotid artery stenting after onset neurologic symptoms

Multicenter clinical trials level 1 evidence favors the application of carotid endarterectomy in symptomatic patients, especially the in the elderly cohort. Carotid artery stenting has been proposed as a possible early alternative in selected patients after onset of ipsilateral neurologic symptoms. It is well known that treatment of acute stroke is time-dependent in patients with acute ischemic stroke caused by high-grade stenosis of the internal carotid artery, but intensive medical treatment in conjunction with intervention to improve stroke severity and clinical outcomes has not been established. Two major clinical concerns exist: (1) the risk of hemorrhagic infarction after cerebral revascularization in the acute stage and (2) application of carotid stenting in the acute embolic stage, which may be associated with continued embolic risk after carotid artery stenting compared to carotid endarterectomy, which removes the symptomatic plaque. This review summarizes the indications and results of early carotid artery stenting after onset of neurologic symptoms, considering the new carotid stents and cerebral protection systems available for clinical use and enhanced stenting techniques.

The timing of stereotactic radiosurgery for medically refractory trigeminal neuralgia: the evidence from diffusion tractography images.

Diffusion tensor imaging (DTI) is a novel MRI technique that enables noninvasive evaluation of microstructural alterations in white matter of brain. Initially, DTI was used in intra- or inter-hemispheric association bundles. Recent technical advances are overcoming the challenges of imaging small white matter bundles, such as the cranial nerves. In this study, we use DTI to shed more light on the microstructure changes in long-standing trigeminal neuralgia. We also utilize DTI to study the effect of early stereotactic radiosurgery (SRS) on the microstructures of the trigeminal nerve and to predict the effectiveness of early SRS in the treatment of medically refractory trigeminal neuralgia (TN). To analyze the presentation of trigeminal nerve, the DTI was reconstructed in 21 cases pre- and post-SRS. DTI parameters recorded include fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), axial diffusivity (AD), linear anisotropy coefficient (Cl), planar anisotropy coefficient (Cp), and spherical anisotropy coefficient (Cs). Comparisons between ipsilateral (symptomatic) and contralateral (asymptomatic) trigeminal nerves and symptom durations of < 5 and ≧5years were performed. The study cohort comprised 21 patients with TN with a median age of 66years. Initial adequate facial pain relief (Barrow Neurological Institute facial pain scores I-IIIb) was achieved in 16 (76%) patients. For the pre-SRS DTI findings, ipsilateral trigeminal nerve was associated with higher baseline root entry zone (REZ) Cs compared to contralateral nerve (0.774 vs. 0.743, p = 0.04). Ipsilateral trigeminal nerve with symptoms of < 5years was associated with higher baseline FA compared to trigeminal nerve with symptoms of ≧5years (0.314 vs. 0.244, p = 0.02). For the post-SRS DTI findings, ipsilateral trigeminal nerves with symptoms of <5years demonstrated decrease in Cl, while those with symptoms ≧5years demonstrated increase in Cl after SRS at the ipsilateral REZ (- 0.025 vs. 0.018, p = 0.04). At the cisternal segment of ipsilateral trigeminal nerve, symptoms of < 5years were associated with decreased FA and increased λ2, while symptoms of ≧5years were associated with increased FA and decreased λ2 after SRS (FA - 0.068 vs. 0.031, p = 0.04, λ2 0.0003 vs. - 0.0002, p = 0.02). SRS provides high rates of initial pain relief with moderate rates of facial hypoesthesia. Ipsilateral trigeminal nerve was associated with higher baseline REZ Cs, and baseline FA was associated with duration of symptoms. There were significant associations between duration of symptoms and changes in ipsilateral REZ Cl, cisternal segment FA, and cisternal segment λ2 after SRS. These preliminary findings serve as comparisons for future studies investigating the use of DTI in radiosurgical planning for patients with TN.

Abstract 85: Is Progressively Worsening Severity of Internal Carotid Artery Stenosis by Carotid Doppler Ultrasound in Asymptomatic Patients a Risk Factor for Ischemic Stroke?

Background: Progressively worsening severity of ICA stenosis has been used as an indication for carotid revascularization in asymptomatic patients. However, limited data exists whether progression in severity is actually associated with ipsilateral cerebral ischemic symptoms. Methods: We analyzed data from the Cardiovascular Health Study participants aged ≥65 years who underwent serial carotid Doppler ultrasound (at baseline and 5 year follow up). The severity was classified into four grades by a central reader: 0-24%, 25-49%, 50-69%, 70-99%, and complete occlusion. We selected patients who were asymptomatic at baseline and not undergone carotid endertectomy. Progressively worsening severity of internal carotid artery stenosis was defined if the severity of ICA with highest velocity at baseline evaluation had increased by one grade or greater at 5 year follow up. Incident cardiovascular events were identified during annual follow-up examinations and at 6-month telephone contact and adjudicated by a central committee. Hazards ratio for cardiovascular events during follow up were estimated using Cox proportional Hazards analysis. Results: Progressively worsening severity of internal carotid artery stenosis was observed in 1551 (26.3%) of 5,888 study participants (57.2% women; mean baseline age, 72.7 ± 5.1 years). The rate of ipsilateral ischemic stroke was similar among patients with and without progressively worsening severity of internal carotid artery stenosis over a mean follow up period (mean ±SD) of 7.3 ± 1 years. The risk of any ischemic stroke was (HR 1.3, 95% confidence interval [CI] 1.0-1.6) but not ipsilateral ischemic stroke (HR 1.4, 95% CI 0.6 - 3.1) was statistically higher among patients with progressively worsening severity of internal carotid artery stenosis after adjusting for age, race, serum cholesterol, diabetes mellitus, blood pressure and cigarette smoking. The risk of MI (HR 1.3, 95% CI 1.1-1.7) was significantly higher among patients with progressively worsening severity of internal carotid artery stenosis. Conclusions: Patients with progressively worsening severity of internal carotid artery stenosis appear to be at higher risk of cardiovascular events but not ipsilateral cerebral ischemic symptoms.

Spotty Carotid Plaques Are Associated with Inflammation and the Occurrence of Cerebrovascular Symptoms

Background: Echolucent carotid plaques have been related to an increased risk of ischemic cerebrovascular events. The aim of the present study was to evaluate whether a new objective ultrasonographic parameter, the statistical geometric feature (SGF), reflecting spottiness of carotid plaques, can be associated with cerebrovascular symptoms and with a rupture-prone plaque phenotype. Methods: The plaques of 144 patients who underwent carotid endarterectomy were included in this study. SGF and plaque area were estimated by outlining the plaque on ultrasound (US) images. The correlation coefficient for inter- and intraobserver variability was 0.69 and 0.93, respectively. The SGF values were normalized to the degree of stenosis (SGF/DS). The plaques collected at surgery 1 day after the US were analyzed histologically, and inflammatory markers and matrix metalloproteinases (MMPs) were measured. Results: Patients with ipsilateral hemispheric symptoms had higher SGF/DS compared to patients without symptoms (0.82 [0.59–1.16] vs. 0.70 [0.56–0.89], p = 0.01). Analysis of plaque components revealed a positive correlation between SGF/DS and the percentage of the plaque area stained for lipids, macrophages, and hemorrhage. A correlation was also found between SGF/DS and plaque expression of interleukin-6, monocyte chemoattractant protein-1, macrophage inflammatory protein-1β, vascular endothelial growth factor A, C-C motif chemokine 3 and 20, and MMP-9. An inverse correlation was found with plaque levels of osteoprotegerin. Conclusions: The present study supports the concept that spottiness is a feature of the carotid plaques rich in inflammation and can be associated with the typical phenotype of high-risk plaques.

Carotid Near-Occlusion Stent Experiences.

Treatment strategy for near-occlusions (NO) of the internal carotid artery (ICA) is still controversial. In this study, we aimed to present the clinical results of stent placement in 50 patients with carotid artery (NO) stenosis that presented to our center, and upon which revascularization will be performed. Between 2014 and 2017, 50 patients with (NO) from 180 patients who had stents in the Interventional Vascular Neurology clinic were retrospectively studied. All the patients whether using or not using the proximal and distal protection device during the procedure were included. Patients had clinical neurologic evaluation, and underwent carotid artery radiologic imaging before the carotid artery stent (CAS) procedure. Balloon dilatation was applied before the stent procedure for patients that had advanced stenosis. Post-dilatation was applied with a balloon of appropriate size in case of residual narrowing. Findings such as bradycardia, hypotension, reperfusion hemorrhage during and after the stent placement procedure, as well as patients that developed restenosis within 12 months were recorded. This study includes 50 (30 males, 20 females) patients that underwent carotid stent placement. The mean age of patients was 65 (28-81). Reperfusion hemorrhage was seen in 1 (2%) patient and the patient died in week 3. Ten (20%) patients complained of chills and tremor lasting less than 3 hours after the procedure. One (2%) patient had encephalopathy and agitation for less than 24 hours. Two (4%) patients had hypotension, and 15 (30%) patients had a headache for less than 24 hours. Three patients developed local hematoma at the site of the sheath, and were treated by applying compression. Restenosis signs in the stent site was observed in 6 patients (12%) in color Doppler ultrasonography of the carotid performed in the 6th and 12th months. Although the innate process of ICA NO is not well known, it might be more frequent than currently considered. Especially after the diagnosis of ICA stenosis, it is important to make the right diagnosis in patients that have new ipsilateral symptoms. After the diagnosis is made, CAS, when performed by an experienced neuro-interventional team, seems beneficial with low complication rates.

Clinical Manifestations of Isolated Chronic Middle Cerebral Artery Occlusion in Relation to Angiographic Features.

Isolated chronic middle cerebral artery occlusion (ChMCAO) is not a rare condition and is known to cause hemodynamic stroke. The purpose of this study was to evaluate differences in clinical manifestations and prognosis of isolated ChMCAO in relation to angiographic features. This retrospective study enrolled 56 patients with isolated ChMCAO. In accordance with degree of anterograde collateral flow (AF) on angiography, patients were categorized into poor and good AF groups. The 2 groups were assessed and compared for the presence and recurrence of neurologic symptoms. Of 56 patients, 33 were in the poor AF group and 23 were in the good AF group. The prevalence of ischemic symptoms was significantly higher in the poor AF group compared with the good AF group (P < 0.05). During an average follow-up period of 33.8 months, recurrent ipsilateral symptoms occurred in 6 of 45 patients. The hazard ratio conferred by poor AF was 5.36 (95% confidence interval, 1.08-26.57) for recurrent symptoms. AF through the basal collateral network may be related to clinical manifestations of ChMCAO. Good AF in isolated ChMCAO may play an important role in preventing recurrence of an ischemic event.

Carotid artery revascularization in patients with contralateral carotid artery occlusion: Stent or endarterectomy?

BackgroundThe Centers for Medicare and Medicaid Services (CMS) considers that contralateral carotid artery occlusion puts the patients at high risk for carotid endarterectomy (CEA) and agrees to reimburse for carotid artery stenting (CAS) in these patients. However, there is a paucity of evidence that support the superiority of CAS compared with CEA in patients with contralateral carotid occlusion. MethodsAll patients who underwent CEA or CAS with contralateral carotid artery occlusion were identified in the Vascular Quality Initiative (VQI) registry between 2005 and 2016. Outcomes examined were stroke, death, and myocardial infarction at 30 days and stroke and death at 2 years stratified by ipsilateral symptomatic status. Multivariable logistic regression analysis was implemented to estimate the odds ratios (ORs) of 30-day outcomes controlling for potential confounders. Life tables, robust Cox proportional hazard clustered by centers, and log-rank tests were implemented to estimate the hazard ratios (HRs) for long-term events. ResultsOverall, 4326 patients had contralateral carotid artery occlusion (CEA: 3274 [75.7%] vs CAS: 1052 [24.3%]). Patients' demographic and comorbidities were generally similar in both groups, except for race, in which nonwhite patients were more likely to have CAS (9.5% vs 7.6%; P = .048). History of stroke was twice as much prevalent in patients undergoing CEA (56.4% vs 24.0%; P < .001). CAS patients were more likely to present with ipsilateral symptoms (41.2% vs 24.2%; P < .05). In asymptomatic patients, the short-term outcomes and 2-year risk of ipsilateral stroke did not differ significantly between CAS and CEA; however, the adjusted risk of any stroke or death over 2 years was 42% higher with CAS (adjusted HR, 1.42; 95% confidence interval [CI], 1.08-1.86; P = .011). In symptomatic patients, CAS was associated with an almost threefold higher risk for 30-day stroke (OR, 2.90; 95% CI, 1.06-7.94; P = .038) and more than sixfold the 30-day mortality (OR, 6.10; 95% CI, 2.20-16.92; P = .001). The risk of stroke in the initial 2 years after surgery was 94% increased in a CAS patient relative to a CEA patient (adjusted HR, 1.94; 95% CI, 1.18-3.19; P = .009). ConclusionsIn this exclusive large cohort of patients with contralateral carotid artery occlusion, CAS did not perform better compared with CEA in asymptomatic patients and had significantly worse outcomes in symptomatic patients in the perioperative period. The 2-year stroke rate was similar between the two procedures, but the risk of stroke or death was consistently higher for CAS patients. CAS is not safer than CEA in patients with contralateral carotid artery occlusion, and refinement of current guidelines is warranted to provide appropriate surgical care specifically tailored for the patient's presentation.

The modified ‘no touch’ technique in the antegrade endovascular approach for left common carotid artery ostial stenosis stenting

BackgroundOpen surgery and the retrograde endovascular approach via the distal left common carotid artery (LCCA) have some limitations in LCCA ostial stenosis treatment. The ‘no touch’ technique used in the...

Unilateral Stimulation of Prelemniscal Radiations for the Treatment of Acral Symptoms of Parkinson’s Disease: Long-Term Results

Prelemniscal radiations (Raprl) have been proposed as a target for the treatment of Parkinson's disease. We evaluated effectiveness of this target through UPDRS-III in patients treated with Raprl deep brain stimulation (Raprl-DBS) and followed from 24 to 48 months. Nineteen patients in Hoehn-Yahr stages II-III were implanted with tetrapolar deep brain stimulation electrodes in Raprl contralateral to the extremities with more prominent symptoms. Placement was assisted by MRI/CT/anatomical atlas fusion, microelectrode recording, and micro- and macro-stimulation. The effect on motor symptoms was evaluated in an open label protocol through specific items of the UPDRS-III score, applied pre-operatively and 6, 12, 24, and 48 months after the onset of stimulation in an OFF-medication/ON-stimulation condition. Changes in scores with regard to pre-operative condition were obtained for each symptom in both sides and statistical significance determined through double-tail Wilcoxon test. Influence of demographic variables on outcome was analyzed using linear regression testing. A greater than 80% decrease in UPDRS score for contralateral symptoms (classified as excellent results) occurred in 14 patients (73.7%), while in the other 5 it decreased from 33 to 79% (considered suboptimal results). These changes remained statistically significant up to 48 months (p < 0.01), while ipsilateral symptoms progressively increased. Suboptimal results were associated with selective improvement of only one symptom. Raprl-DBS induces a long-term, significant improvement of contralateral acral symptoms of Parkinson's disease.

Semiautomated Magnetic Resonance Imaging Assessment of Carotid Plaque Lipid Content

The composition of a carotid plaque is important for plaque vulnerability and stroke risk. The main aim of this study was to assess the potential of semiautomated segmentation of carotid plaque magnetic resonance imaging (MRI) in the assessment of the size of the lipid-rich necrotic core (LRNC). Thirty-four consecutive patients with carotid stenosis of 70% or higher, who were scheduled for carotid endarterectomy, underwent a clinical neurological examination, Color duplex ultrasound, 3-T MRI with an 8-channel carotid coil, and blood tests. All examinations were performed less than 24 hours prior to surgery and plaques were assessed histologically immediately following endarterectomy. Plaques were defined as symptomatic when associated with ipsilateral cerebral ischemic symptoms within 30 days prior to inclusion. The level of agreement between the size of the LRNC and calcification on MRI to the histological estimation of the same tissue components, plaque echolucency on ultrasound, and symptoms was assessed. The size of the LRNC on MRI was significantly correlated to the percentage amount of lipid per plaque on histological assessment (P = .010, r = .5), and to echogenicity on ultrasound with echolucent plaques having larger LRNC than echogenic plaques (P = .001, r = -.7). In this study, we found that semiautomated MRI assessments of the percentage LRNC in carotid plaques were significantly correlated to the percentage LRNC per plaque on histological assessment, and to echogenicity on ultrasound with echolucent plaques having larger LRNC than echogenic plaques.

Surgical management of extracranial carotid artery aneurysms.

We present the methods and results of the surgical management of extracranial carotid artery aneurysms (ECCA). Postoperative complications including early and late neurological events were analysed. Correlation between reconstruction techniques and morphology of ECCA was assessed in this retrospective study. In total, 32 reconstructions of ECCA were performed in 31 symptomatic patients with a mean age of 59.2 (range 33-84) years. The causes of ECCA were divided among atherosclerosis (n = 25; 78.1%), previous carotid endarterectomy with Dacron patch (n = 4; 12.5%), iatrogenic injury (n = 2; 6.3%) and infection (n = 1; 3.1%). In 23 cases, intervention consisted of carotid bypass. Aneurysmectomy with end-to-end suture was performed in 4 cases. Aneurysmal resection with patching was done in 2 cases and aneurysmorrhaphy without patching in another 2 cases. In 1 case, ligature of the internal carotid artery (ICA) was required. Technical success defined as the preservation of ICA patency was achieved in 31 cases (96.9%). There was one perioperative death due to major stroke (3.1%). Two cases of minor stroke occurred in the 30-day observation period (6.3%). Three patients had a transient hypoglossal nerve palsy that subsided spontaneously (9.4%). At a mean long-term follow-up of 68 months, there were no major or minor ipsilateral strokes or surgery-related deaths reported. In all 30 surviving patients (96.9%), long-term clinical outcomes were free from ipsilateral neurological symptoms. Open surgery is a relatively safe method in the therapy of ECCA. Surgical repair of ECCAs can be associated with an acceptable major stroke rate and moderate minor stroke rate. Complication-free long-term outcomes can be achieved in as many as 96.9 % of patients. Aneurysmectomy with end-to-end anastomosis or bypass surgery can be implemented during open repair of ECCA.

Natural History of Asymptomatic Moderate Carotid Artery Stenosis in the Era of Medical Therapy

To determine the incidence and risk factors of carotid stenosis progression in patients with asymptomatic moderate carotid artery stenosis (CAS). Patients with asymptomatic moderate CAS in duplex ultrasound (DUS) were identified from 2003 to 2008, and only those with more than 1 DUS were included during a 5-year follow-up after index DUS. Study end-points were carotid stenosis progression to severe stenosis ≥70%, development of ipsilateral neurologic symptoms (INS), and death. One hundred twenty-nine carotid arteries in 124 patients were included in the study. Carotid stenosis progression occurred in 41 (31.8%) arteries, and 4 (3.2%) patients developed INS during a mean follow-up of 49 months (range, 2-128 months). The 5-year freedom from carotid stenosis progression and development of INS were 63.5% ± 5.3% and 98.1% ± 1.4%, respectively, with no difference from those of statin. There was no significant predictor of carotid stenosis progression, and it was not significantly associated with development of INS. The 5-year actuarial patient survival and symptom-free survival were 95.3% ± 2.7 and 93.4% ± 3.0%, respectively, with no difference from those of statin. The only independent predictor of death and INS/death was a remote history of INS (hazard ratio 18.166, P= 0.021, hazard ratio 4.840, P= 0.046). The incidence of carotid stenosis progression in asymptomatic moderate CAS was high even in popular use of aspirin and statin. Although development of INS was not associated with carotid stenosis progression, it was a risk factor of long-term morbidity and survival.

Ipsilateral hemiparesis in lateral medullary infarction: Clinical investigation of the lesion location on magnetic resonance imaging

BackgroundIn 1946, Opalski reported two cases of Wallenberg syndrome with ipsilateral hemiparesis (IH). His hypothesis seems to be based on the view that IH is caused by post-decussating pyramidal tract damage. Afterwards, other researchers proposed a different hypothesis that ipsilateral sensory symptoms of limbs (ISSL) or ipsilateral limb ataxia (ILA) caused by lateral medullary infarction (LMI) might lead to ipsilateral motor weakness. The present study is aimed to clarify whether IH in LMI patients is attributable mainly to ISSL/ILA or disruption of ipsilateral post-decussating pyramidal tract. MethodsThirty-two patients with acute LMI admitted during the last 13years were divided to IH Group (n=7) and Non-IH Group (n=25). Lesion location/distribution on MRI and neurological findings were compared between the two groups. ResultsLMI involved the lower medulla in all seven IH patients and 12 of 25 Non-IH patients. The lower medullary lesion extended to the cervico-medullary junction (CMJ) in four of seven IH patients and one of 12 Non-IH patients. Definitive extension to upper cervical cord (UCC) was confirmed in none of the patients. ISSL was found in two IH and three Non-IH patients all showing only superficial sensory impairments. ILA or hypotonia was observed in 57% of IH and 60% of Non-IH patients. ConclusionIH in LMI appears to be due mainly to post-decussating pyramidal tract damage at the lower medulla instead of ILA or ISSL participation.

A surprise in the lacrimal sac

To present a case with recurrent dacryocystitis as an unusual complication of medial orbital wall fracture repair with cartilage tissue graft. A 20-year-old male had facial trauma and underwent surgery to reconstruct right medial orbital wall fracture. During follow–up, he presented with continuous epiphora, mucopurulent discharge from the right eye. A thorough history taking indicated that medial orbital fracture was reconstructed with postauricular cartilage. We planned a standard external dacryocystorhinostomy (DCR). During the creation of lacrimal sac flaps, hard tissue was noted in the lacrimal sac. This tissue was excised and sent for pathological examination. The pathological examination revealed cartilage tissue. There were no further ipsilateral symptoms or complications after DCR. In patients with lacrimal system injury related to orbital wall fracture, iatrogenic foreign bodies in the lacrimal sac should be considered in patients with recurrent dacryocystitis who had reconstructive surgery for facial and orbital trauma.

Knee Injury Associated With Acetabular Fractures: A Multicenter Study of 1273 Patients.

The purpose of this study was to determine the incidence and pattern of the knee injury associated with acetabular fractures. Retrospective cohort study. Three level I and one level II trauma centers. A total of 1273 skeletally mature patients treated at 4 trauma centers between November 2004 and December 2013 for acetabular fractures were retrospectively identified from orthopaedic trauma databases. Analysis of all acetabular fractures with knee injury regarding type of acetabular fracture, mechanism of injury, energy of injury, pattern of the knee injury, knee examination findings at initial presentation, intraoperative and on follow-up, requirement for surgery/conservative management, and the associated injuries. The clinical data entered during inpatient stay and office visits were analyzed. Incidence and pattern of the knee injury. One hundred ninety-three of 1273 patients (15%) were found to have ipsilateral knee symptoms within a period of 1 year from the date of injury. The patterns of knee injury included 56 fractures (29%), 49 ligamentous lesions (25%), and 88 miscellaneous (46%) causes including bone bruises, wounds, and swelling. Associated injuries included 85 patients with ipsilateral hip dislocation (45%), 59 pelvic injuries (31%), 61 extremity injuries (32%), 38 head injuries (20%), 37 chest injuries (20%), 23 abdominal and genitourinary injuries (12%), and 7 injuries of the spine (4%). Based on this study, we conclude that knee injuries associated with high-energy acetabular fractures constitute a significant portion of the patient population. Ligament injuries are frequently overlooked and thorough clinical evaluation and utilization of magnetic resonance imaging in selected cases will help in early detection and prevention of long-term complications. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cluster Headache: Special Considerations for Treatment of Female Patients of Reproductive Age and Pediatric Patients.

Cluster headache is a rare disorder that is more common in adult male patients. It has a unique phenotype of unilateral, severe, to very severe headaches lasting 15 to 180 min with ipsilateral autonomic symptoms. Time to correct diagnosis can be protracted. A number of treatment options exist for the standard cluster headache patient, but special considerations must be made for female patients of reproductive age and pediatric patients. The objective of this article is to explore the current literature pertaining to special considerations in cluster headache management, including treatment of pregnant or breastfeeding patients and pediatric patients.

Incidence of Ureteric injury in complicated cesarean section and late complications

Background;Most common operation in gynecological department is c/s ,high percentage of c/s are complicatedresulting with many early and late complication, one of intraoperative complication is ureteric injury and or ureteric ligation.Patients and methods:through 3 years between may 2011- may 2014 on 34 patients get ureteric injury in a complicated C/S discovered either intra operatively or as an early post operative complication with confirm diagnosis by IVU. those patients correct the defect by re anastamosis with ureteric catheterization for two months then fallow up to detect any post operative ipsilateral renal complication.Results:We get 26 patient (76.4%) was complain from intermittent ipsilateral renal symptoms , repeated U/S showing ipsilateral mild dilated PCS with chronic U.T.I in general urine examination.Conclusion:Ureteric injury may lead to chronic complaining of the patients from chronic U.T.I and a sequence ofureteric stenosis , so we advise that in any complicated C/S we need a urosurgical doctor in addition to the gynecologist surgeon to avoid as much as possible ureteric injury.Aim of study:To assess the incidence of ureteric injury with a complicated C/S.