Ischemic Neuropathy Research Articles

Ischemic monomelic neuropathy: A rare complication after brachiocephalic arteriovenous fistula

Ischemic monomelic neuropathy (IMN) is a rare neuropathy of the distal nerves due to ischemia secondary to acute loss of proximal arterial supply as a result of shunting or non-compressive occlusion. The main features of IMN are multiple distal focal mononeuropathies with axonal injury. A 71 years old female patient with history of end stage renal disease on hemodialysis and type 2 diabetes. Presented with right hand persistent pain and reduced hand function that started 24 h after formation of right brachiocephalic arteriovenous (AV) fistula. Doppler scan was done suggesting of steal syndrome. Patient then underwent MILLER banding procedure for the fistula. Despite good vascular supply, the right hand pain did not improve and was partially responding to gabapentin and codeine+ paracetamol. On examination: The right hand was warm and the capillary refill was satisfactory, palpable radial pulse with no signs of tissue ischemia. She was unable to flex the wrist and fingers of the right hand and she had clawing of right hand. She had allodynia and hyperalgesia in the distribution of right median, ulnar nerves. Nerve conduction study showed absent sensory responses from the right median, ulnar and radial nerves. The right median and ulnar motor responses were significantly attenuated suggestive of a severe axonal neuropathy and peripheral neuropathy secondary to diabetes. She was referred to vascular surgery for fistula ligation. IMN is a potentially rare devastating complication of arteriovenous access for hemodialysis which can result in permanent disability.

Un effet indésirable rare de l’amiodarone : la neuropathie optique

IntroductionThe diagnosis of bilateral papilledema implies emergency medical care to look for intracranial hypertension and arteritic ischemic neuropathy. However, other causes must also be mentioned, including drugs. Too often underrated because of their usual benignity, drug side ophthalmological effects can be severe and are typically bilateral. Case reportAn 80-year-old woman was hospitalized for bilateral papilledema, predominantly in the left eye, with lowered visual acuity. After ruling out intracranial hypertension, arteritic ischemic optic neuropathy, non-arteritic, and inflammatory bilateral papilledema, the diagnosis was toxic optic neuropathy. ConclusionBilateral edematous optic neuropathy is a known side effect of amiodarone, uncommon but to be known because of the large number of patients benefiting from this treatment.

Predictors of falls and fractures in patients (pts) with nonmetastatic castration-resistant prostate cancer (nmCRPC) treated with apalutamide (APA) plus ongoing androgen deprivation therapy (ADT).

5025 Background: SPARTAN, a phase 3 study of APA vs placebo (PBO) added to ongoing ADT in pts with nmCRPC, demonstrated that APA significantly prolongs metastasis-free survival, time to symptomatic progression, and second progression free survival (Smith et al. NEJM 2018), with no decline in health-related quality of life (Saad et al. Lancet Oncol 2018). SPARTAN pts who received APA, vs PBO, with ongoing ADT had higher rates of falls (15.6% vs 9.0%) and fractures (11.7% vs 6.5%). An analysis was performed to identify clinical characteristics associated with falls and fractures in APA-treated SPARTAN pts. Methods: Of 1207 pts enrolled, 806 were randomized to APA. Univariate Cox proportional hazards model (UVA) assessed the association of 47 baseline clinical characteristics (demographics, comorbidities, and medication use, including bone-sparing agents) with time to fall or time to fracture. Characteristics with p values < 0.10 were included in a multivariate Cox proportional hazards model (MVA) to determine independent factors associated with these outcomes (p < 0.05). Results: Factors associated with time to both fall and fracture on UVA (p < 0.10) included older age, low serum albumin, and poor ECOG performance status (PS). Additional factors associated with time to fall were cerebrovascular accidents/transient ischemic attacks, neuropathy, depression, α-blocker use, and antidepressant use. On MVA, older age, poor ECOG PS, history of neuropathy, and α-blocker use were independently associated with falls; older age and low serum albumin were independently associated with fractures (Table). Conclusions: At initiation of APA added to ongoing ADT, nmCRPC pts with higher risk of falls and fractures can be identified and are candidates for intervention to reduce the risk for these events. Clinical trial information: NCT01946204. [Table: see text]

Protocolo diagnóstico del paciente con diplopía

Diplopia is the simultaneous perception of two images of a single object. It's a prevalent symptom caused by a wide range of etiologies, like myasthenia gravis (fluctuating diplopia) or Graves’ disease (thyroid ophthalmopathy). The most common cause of dipoplia is cranial ischemic neuropathy, in which three ocular motor nerves can be involved. A pupil-involving third nerve palsy requires angiography evaluation for the possibility of an intracranial aneurysm. Intracranial hypertension is a frequent cause of sixth nerve palsy. Fourth nerve palsy usually occurs after cranial trauma. The involvement of brain-stem structures causes complex conditions, among which internuclear ophthalmoplegia, usually of ischemic or demyelinating origin, is noteworthy. Diagnostic and therapeutic approach is achieved by detailed anamnesis and thorough physical examination.

MULTI-LEVEL DAMAGE OF PERIPHERAL NERVOUS SYSTEM IN CLINICAL PRACTICE OF NAVAL AND MILITARY MEDICINE

Damage to the peripheral nerves and spinal roots in natural anatomical tunnels is not only a common form of damage to the nervous system, but also an important medical and social problem; because tunnel neuropathy and degenerative-dystrophic diseases of the spine are one of the most common reasons for the release of citizens from the call, the dismissal of military personnel from the Armed Forces of the Russian Federation, seafarers, changes in the category of fitness for military service. According to various authors, the combination of compression — ischemic neuropathies with signs of spinal cord lesions occurs in 30–70% of cases of tunnel syndromes. This is especially true for seafarers, because they are more likely to be affected by the musculoskeletal system, as long-term, monotonous load can lead to micro-traumatization and micro-hemorrhage, followed by scarring of muscles, tendons, ligaments, fascia and, as a consequence, the narrowing of natural anatomical tunnels. Revealed the existence of a relationship between the sea and the frequency of lesions of the spine, the shoulder girdle, with the emergence of the syndrome of the rotator cuff and carpal tunnel syndrome. In military personnel, this may occur during excessively long compression of the upper arms during shooting, training, work in low temperatures and vibration.

Ganglion cyst of Guyon’s canal as a rare cause of compression neuropathy of the ulnar nerve (literature review and case report)

The study objectiveis to analyze the existing research literature devoted to this problem and to assess clinical characteristics and specific features of the diagnosis and rational neurosurgical treatment for ganglion cyst of Guyon’s canal (GCGC) that caused compression neuropathy of the ulnar nerve.Materials and methods.Since 1955, researchers reported only 19 cases of ganglion cysts located in the wrist area and associated with tunnel neuropathy of the ulnar nerve. Since this condition is extremely rare, we present our own clinical observations.Results.Using the literature data, we described various types of ulnar nerve compression according to individual nerve characteristics determining clinical manifestations of GCGC. We analyzed the prevalence of GCGC among patients of various age and gender, disease pathogenesis, and main diagnostic methods. A patient with GCGC-associated compression ischemic neuropathy of the ulnar nerve was treated in the neurological clinic of the I. M. Sechenov First Moscow State Medical University in 2016. Using visualization tools, we found a ganglion cyst located on the palmar surface at the level of the hook-shaped bone. The cyst caused medial displacement of the ulnar nerve and ulnar artery. We performed microsurgical decompression of the right ulnar nerve at the level of Guyon’s canal and removed the articular ganglion cyst using a standard procedure. In the postoperative period, we observed partial regression of neurological disorders.Conclusion.To identify the cause of ulnar nerve neuropathy in Guyon’s canal, a physician should consider both clinical and electrophysiological data and the results of ultrasound examination and/or magnetic resonance imaging. A detailed examination of these patients allows clarifying morphological characteristics of the lesion and identifying such a rare lesion as ganglion cyst.

Citicoline and Retinal Ganglion Cells: Effects on Morphology and Function.

Background: Retinal ganglion cells (RGCs) are the nervous retinal elements whichconnect the visual receptors to the brain forming the nervous visual system. Functional and/or morphological involvement of RGCs occurs in several ocular and neurological disorders and therefore these cells are targeted in neuroprotective strategies.Cytidine 5-diphosphocholine or Citicoline is an endogenous compound that acts in the biosynthesis of phospholipids of cell membranes and increases neurotransmitters’ levels in the Central Nervous System. Experimental studies suggested the neuromodulator effect and the protective role ofCiticoline on RGCs. This review aims to present evidence of the effects of Citicoline in experimental models of RGCs degeneration and in human neurodegenerative disorders involving RGCs.Methods: All published papers containing experimental or clinical studies about the effects ofCiticoline on RGCs morphology and function were reviewed.Results: In rodent retinal cultures and animal models, Citicoline induces antiapoptotic effects,increases the dopamine retinal level, and counteracts retinal nerve fibers layer thinning. Human studies in neurodegenerative visual pathologies such as glaucoma or non-arteritic ischemic neuropathy showed a reduction of the RGCs impairment after Citicoline administration. By reducing the RGCs’ dysfunction, a better neural conduction along the post-retinal visual pathways with an improvement of the visual field defects was observed.Conclusion: Citicoline, with a solid history of experimental and clinical studies, could be considered a very promising molecule for neuroprotective strategies in those pathologies (i.e. Glaucoma) in which morpho-functional changes of RGCc occurs.

A Case of Rheumatoid Cerebral Vasculitis Presenting to the ED

Central nervous system involvement in rheumatoid arthritis is infrequent. The most frequent neurological manifestations of rheumatoid arthritis are peripheral neuropathy and cervical spinal cord compression due to subluxation of the cervical vertebrae. Cerebral rheumatoid vasculitis is an uncommon and serious complication which can be life-threatening Neurological involvement in RA is rare, present in only 1% of patients. Disorders of the central nervous system (CNS) include cervical myelopathy, vasculitis, RNs located within the CNS, or meningitis. Stroke also occurs with increased frequency. CNS vasculitis is extremely rare. The diagnosis is supported by magnetic resonance imaging (MRI), alone or with magnetic resonance angiography (MRA), showing the segmental vascular stenosis characteristic of vasculitis. Peripheral neuropathy is usually manifested as sensorimotor neuropathy or mononeuritis multiplex. The underlying mechanism is small vessel vasculitis of the vasa vasorum of the nerves with ischaemic neuropathy and demyelinisation as part of the rheumatoid vasculitis (RV) syndrome. Rheumatoid vasculitis typically affects small and medium-size blood vessels. It is associated with high rates of premature mortality with up to 40% of patients dying by 5 years as well as significant morbidity due to both organ damage from vasculitis and consequences of the treatment. High levels of circulating immune complexes have been observed in atients with rheumatoid vasculitis, and in particular high serum levels of rheumatoid factor are often detected at the time of onset of vasculitis.Deposition of immune complexes most likely contributes to small vessel inflammation and organ damage. Anti CCP levels also tend to be higher in patients with RA who have systemic vasculitis than in those who do not. Histologically, rheumatoid vasculitis involves blood vessels of the small arteries, and all layers of the vessel wall are infiltrated by neutrophils, lymphocytes, and plasma cells.

Risk of Mortality After Resolution of Spinal Malperfusion in Acute Dissection

Spinal cord ischemia (SCI) may develop in patients presenting with acute aortic dissection. We sought to determine how SCI and its recovery affect outcomes. We reviewed patients with SCI in acute type A aortic dissection (ATAAD) and acute type B aortic dissection (ATBAD) from September 1999 to May 2014. SCI was defined as paraplegia or paraparesis present on admission. Monoparesis/plegia, paraesthesia, or numbness was defined as ischemic neuropathy. All ATBAD patients were managed with antiimpulse therapy, with selective intervention for rupture, rapid aortic expansion, malperfusion, or intractable pain. ATAAD patients were managed with urgent proximal aortic replacement. Neurologic symptoms were present in 178 (18.2%) of 978 acute dissections (482 ATAAD and 496 ATBAD). Of these 178 patients, SCI presented in 52 patients (29.2%; 80.1% male; mean age, 57 years). On admission paraplegia was present in 24 (46.2%), paraparesis in 10 (19.2%), paresthesia/numbness in 27 (51.9%), and leg ischemia in 25 (48.1%). Aortic operations were performed in 27 SCI patients (51.9%). Symptom resolution was seen in 30 (57.7%). The 30-day mortality was 19.2% and was significantly less in those with resolution of SCI (6.7% vs 36.4%, p= 0.012). When surgical intervention was required in ATBAD with SCI, mortality was 50% (p= 0.039). SCI and symptom resolution significantly affected overall survival. SCI is associated with significantly increased risk of overall mortality (hazard ratio, 2.9; p < 0.001), and SCI resolution completely offsets this risk (hazard ratio, 0.28; p= 0.003). These effects were consistent between ATAAD and ATBAD (p= 0.554). SCI in acute aortic dissection portends a poor prognosis. However, reversal of deficits is associated with a long-term survival outcome comparable to patients unaffected with SCI.

Could Platelet Indices and Neutrophil to Lymphocyte Ratio Be New Biomarkers for Differentiation of Arteritic Anterior Ischemic Neuropathy from Non-Arteritic Type?

ABSTRACTThe aim of this study was to assess the possible relationship between AAION (arteritic anterior ischemic optic neuropathy) and NAION (non-arteritic anterior ischemic optic neuropathy) with blood platelet parameters and NLR (neutrophil-to-lymphocyte ratio). The medical records of 12 patients with AAION, 33 patients with NAION, and 35 healthy subjects were examined. MPV, PDW, and PCT values showed marked elevation in AAION and NAION groups compared with control group. The mean NLR was statistically significantly higher only in AAION group compared to the NAION and control groups, suggesting that platelet function plays an important role in AIONs and NLR might be used to differentiate AAION from NAION.

Bilateral Delayed Nonarteritic Anterior Ischemic Neuropathy Following Acute Primary Angle-closure Crisis

Bilateral Delayed Nonarteritic Anterior Ischemic Neuropathy Following Acute Primary Angle-closure Crisis

Bilateral irreversible visual loss due to arteritic anterior optic ischemic neuropathy

Introduction: Anterior optic ischemic neuropathy (AOIN) is the most frequent cause of visual loss in giant cell arteritis (GCA). As blindness is rarely reversible, the main therapeutic goal is to prevent bilateral disease by immediate initiation of high-dose intravenous steroids. Approximately, one third of patients present with bilateral visual impairment. Case Report: A 77-year-old patient, came to the Ophthalmology Emergency Room for sudden loss of vision in the left eye (OS) to no light perception (NLP) with two days duration and significant narrowing of the visual field in the right eye (OD) with 10 hours duration. Fundus examination revealed swelling and pallor of the optic disc in both eyes (OU). Laboratory examination showed elevated ESR (56 mm/h) and CRP (5.24 mg/dl). Temporal artery biopsy (TAB) proved granulomas and fibrosis within the vessel wall. Immediate Methylprednisolon 1gm was administered intravenously for five days, followed by oral Prednisone 1mg/kg for four weeks with tapering of 10 mg per month. The patient was put on diabetic and low sodium regimen. During the 3rd day of treatment, vision OD dropped to NLP. Despite continuing systemic steroid therapy, vision remained unchanged. Two months following discharge, the patient died from myocardial infarction. Conclusion: Irreversible bilateral blindness occurred in a patient with arteritic AOIN, while he was on systemic steroids, probably due to late presentation, when vision was already affected bilaterally.

Stellar Neuroretinitis Revealing Systemic Lupus Erythematosus without Antiphospholopid Syndrome

Introduction: Systemic Lupus Erythematosus (SLE) is an autoimmune systemic disease with multiple faces, secondary to auto-reacting antibodies targeting nuclear antigen. The optic nerve involvement is reported in less than 1% of SLE, dominated by optic neuritis and optic ischemic neuropathy. neuroretinitis is defined as an inflammation of optic nerve and neural retina. We report a rare case of neuroretinitis as revealing form of SLE in young man. Case report: 14 y old teenager boy, previously healthy, presented one month before his admission, rapidly progressive bilateral visual loss with no associated signs. Visual acuity evaluation revealed visual loss estimated to 2/10 right eye and 3/10 left eye with correction. Eye fundus objectified bilateral stellar macular with intermacularoptic disc exudates and moderate papillar pallor. The macular OCT found exudates in the plexiform layer of the retina. Other paraclinical test found bicytopenia with positive antinuclear and anti-DNA antibody; without antipospholipid antibody. The patient underwent corticotherapy with favourable evolution. Discussion: Neuroretinitis did not figure as usual cause of visual loss in SLE; moreover it has been very rarely reported as a revealing form of SLE. The exact pathogenesis behind neuroretinitis in SLE stays unknown. Sudden onset of unilateral painless loss of vision is the typical clinical presentation of neuroretinitis. Several etiologies may lead to neuroretinitis, dominated by infectious disease (bartonellosis, borreliosis, syphilis, herpes, hepatitis, HIV, CMV, Varicelle, EBV, Toxoplasmosis, Tuberculosis). Also neuroretinitis may be idiopathic. Concerning therapy, no clear guidelines are reported in neuroretinitis occurring in SLE. The visual prognosis is excellent with above 90% cases achieving a final visual acuity. Conclusion: We learn from this case, that neuroretinitis may be the revealing form of SLE. This suggest the need of revision of SLE criterion, especially that neuroretinitis is a part of severe form.

La biopsia de arteria temporal. Una experiencia de 25 años

IntroductionTemporal arteritis or giant cell arteritis is the most common systemic inflammatory vasculitis in adults, affecting large and medium-sized vessels, typically braches of the carotid artery. Treatment is with high-dose corticosteroids. A lack of treatment could lead to important consequences, the most serious of which is visual loss due to anterior ischemic neuropathic neuropathy. Material and methodsA retrospective revision of the temporal artery biopsies done in our center in the past 25 years was carried; a descriptive and analytic study was done. ResultsA total of 620 biopsies were done on patients between 1991 and 2016. 18.4% of them were positive. 68.5% of the patients were female, and the average age was 75.8 years. The length of the biopsy and erythrocyte sedimentation rate (ESR) and C-reactive protein levels of the patients biopsied after 2011 (n = 142) were documented. No significant differences were found between the 2groups (positive and negative biopsies) for any of the 3variables. ConclusionTemporal artery biopsy is still the gold standard diagnostic test. The variables with the highest predictive value are the increase in ESR levels, and clinical symptoms (visual disturbances and new-onset headache). The time between diagnostic suspicion and biopsy is crucial, in order to confirm the diagnosis and, initiate, adjust or suspend corticosteroid treatment, and prevent irreversible complications.

Abducens nerve palsy after orbital decompression

ABSTRACTIntroduction: Double vision after decompression surgery for Thyroid Eye Disease (TED) is well described in the literature and the incidence ranges from 0 to 64%. The Mechanisms for new onset diplopia after orbital decompression are poorly understood. Common theories include: Fibrosis of muscles, displacement of the muscle cone, and reactivation of the TED.Aim: We present two cases with Abducens nerve palsy after uncomplicated secondary orbital decompression surgery.Results: Two patients with inactive TED, who were followed for an average of 2 years prior to uneventful secondary decompression surgery, presented at the first postoperative visit with double vision and limitation of abduction in the recently operated eye. Magnetic resonance imaging(MRI) was done in both cases and revealed no abnormal bleeding or scaring.Discussion: Our two cases of Abducens palsy following reoperative orbital decompression may be due to ischemic neuropathy caused by postoperative hemorrhage or inflammation.

Neurologic Manifestations of Rheumatoid Arthritis.

Neurologic manifestations of rheumatoid arthritis (RA) range in severity from mild paresthesias in the hand from carpal tunnel syndrome to sudden death due to impingement of the medulla by an eroded, vertically subluxed dens. Most neurologic complications are a consequence of articular inflammation and damage that leads to compression of adjacent structures of the central or peripheral nervous systems. Rare but serious extra-articular manifestations include inflammation of the meninges and ischemic neuropathies due to necrotizing arteritis of the vasa vasorum. Medical therapy with synthetic disease-modifying antirheumatic drugs and biological agents has diminished the incidence of serious neurologic manifestations in RA.

Involvement of the Peripheral Nervous System in Polyarteritis Nodosa and Antineutrophil Cytoplasmic Antibodies-Associated Vasculitis.

Peripheral nerve involvement is common in polyarteritis nodosa and the antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. The underlying mechanism is arteritis of the vasa nervorum, leading to ischemic neuropathy. The classic presentation is stepwise involvement of peripheral nerves with ongoing antecedent constitutional symptoms. This article reviews the pathologic findings, clinical syndromes, diagnosis, and treatment of ANCA-associated vasculitides.

Role of the rs2274907 allelic variant of the ITLN1 gene in patients with diabetic foot.

INTRODUCTION Diabetic foot (DF) is a serious complication of diabetes mellitus (DM) that occurs dueto neuropathy or atherosclerosis of the lower limbs. Omentin (encoded by the ITLN1 gene) has beenimplicated as a protective factor in vascular complications of diabetes, likely due to its endothelialvasodilator activity and its anti‑inflammatoryactions. However, susceptibility to DF with respect to theallelic variants of the ITLN1 gene has not been studied so far. OBJECTIVES This study aimed to evaluate the association between the rs2274907 allelic variant of theITLN1 gene and the occurrence of DF in patients with type 2 diabetes mellitus (T2DM). PATIENTS AND METHODS The study included 670 individuals: 204 with T2DM and DF (DF group), 299with T2DM without DF (T2DM group), and 167 healthy controls. RESULTS Ischemic heart disease, retinopathy, nephropathy, neuropathy, obesity, hyperlipidemia, andactive smoking were more frequent in the DF group than in the T2DM group. Allele A of the rs2274907variant was observed more frequently in the DF group compared with healthy controls in an additivemodel (odds ratio [OR] = 0.7, P = 0.034). This effect was also sex‑specificfor males in both the additiveand recessive models (OR = 0.6, P = 0.015 and OR = 0.52, P = 0.0017, respectively). However,no differences in the distribution of alleles was observed between the DF and T2DM groups. CONCLUSIONS The rs2274907 variant of the ITLN1 gene is associated with increased prevalence of DF.

Ischemic Sciatic Neuropathy in a Patient with Liposarcoma

Background Various etiologies are the causative agents for sciatic neuropathy. We present here a case of ischemic sciatic neuropathy in a patient with liposarcoma. Case report A 55-year-old woman presented with severe pain and weakness of the left leg. She had a history of recurred retroperitoneal liposarcoma, and was being administered chemotherapy. Examination revealed weakness in ankle dorsiflexion, plantar flexion and hamstring. Complaints also included dysesthesia, and numbness in the sole and dorsum of the foot. Nerve conduction study showed low compound muscle action potentials and slow motor conduction velocity of left peroneal and tibial nerves, with indiscernible sensory nerve action potentials of the left superficial peroneal and sural nerves. Computed tomography angiography revealed occlusion of the left common iliac artery. Commencement of intravenous infusion of heparin resulted in skin color change and progression of the weakness. Hence, the patient underwent an emergency thrombectomy. Conclusions Ischemia should be considered as a cause of sciatic neuropathy in cancer patients, which requires management with timely treatment. Key Words: Sciatic neuropathy; Liposarcoma; Ischemia

Medicaments administration into the subtenon eye space in treatment of anterior ischemic neuropathy.

In spite of treatment provided inanterior ischemic neuropathy, a prognosis for visual functions is poor and depends on severity of affection ofvascular system of the body. We have studied the exposure to cortexin and diprospan in subtenon administration on the eye hemodynamics in 18 patients experiencing anterior ischemic neuropathy(18 eyes) who have been treated operatively (administration of cortexin and diprospan into the subtenon space of the affected eye) against the background of complex conservative prevention. The control group was constituted of 16 patients (16 eyes) who have not been treated operatively. As a result of provided treatment the patients of the basic group showed increase of vision acuity, field of view limits and eye ground state.