Ischemic Neuropathy Research Articles

Factors associated to temporal artery biopsy result in suspects of giant cell arteritis: a retrospective, multicenter, case-control study

To evaluate the positivity rate of temporal artery biopsies (TAB) performed in suspects of giant cell arteritis (GCA) and to study the epidemiological and clinical factors associated to the biopsy result. A retrospective, multicenter, case-control study was performed, including three hundred and thirty-five patients who underwent TAB for a suspicion of GCA from 2001 to 2010. Clinical, epidemiological and pathology data were recovered from the patients' clinical records. Histologic diagnosis of GCA was made when active inflammation or giant cells were found in the arterial wall. Eighty-one biopsies (24.2%) were considered positive for GCA. Clinical factors independently associated to TAB result in a logistic regression analysis were temporal cutaneous hyperalgesia (OR = 10.8; p < 0.001), jaw claudication (OR = 4.6; p = 0.001), recent-onset headache (OR = 4.4; p = 0.001), decreased temporal pulse (OR = 2.8; p = 0.02), pain and stiffness in neck and shoulders (OR = 2.3; p = 0.05), unintentional weight loss (OR = 1.33; p = 0.003) and age (OR = 1.085; p = 0.004). Other factors such as length of the surgical specimen (OR = 1.079; p = 0.028) and erythrocyte sedimentation rate (OR = 1.042; p < 0.001) were also statistically significant. The model was accurate (C-index = 0.921), reliable (pHosmer-Lemeshow = 0.733) and consistent in the bootstrap sensitivity analysis. No significant association was detected between TAB result and number of days of previous systemic corticosteroid treatment (p = 0.146). However, an association was observed between TAB result and the total accumulated dose of previous systemic corticotherapy (p = 0.043). Exhaustive anamnesis and clinical examination remain of paramount importance in the diagnosis of GCA. To improve the yield of TAB, it should be performed specially in older patients with GCA-compatible clinic. TAB could be avoided in patients with an isolated elevation of acute phase reactants, without GCA-compatible clinic.

Ocular manifestations of Takayasu arteritis

AbstractPurpose Takayasu arteritis is an inflammatory vascular disease of aorta and its branches. Ophthalmologic manifestations can occur up to 68% of patients and can be inaugural. The objective of this series is to describe the typical and atypical ocular manifestations of the diseaseMethods Bicentric (Pitié‐Salpêtrière and Lariboisière Hospitals) and multidisciplinary retrospective study conducted between 2004 and 2012, describing ocular manifestations of patients with Takayasu arteritis.Results Seven patients, 3 men and 4 women, were included. Mean age was 51(range:31‐70 years). Five patients had previously a confirmed diagnosis of Takayasu (71% type V) and 2 presented with inaugural ocular involvement. Most of the patients were asymptomatic(42%). We identified 5 typical manifestations , including 3 Takayasu retinopathy (42%),1 hypertensive retinopathy(15%) and 1 mixed retinopathy (15%). Atypical manifestations included a bilateral central retinal artery occlusion, a branch retinal vein occlusion and a transient monocular blindness. Treatment consisted of systemic administration of corticosteroids and immunosuppressors, symptomatic and secondary preventive therapy (laser photocoagulation on ischemic areas). Takayasu arteritis causes various ophthalmic manifestations such as traditional hypoperfusion retinopathy and hypertensive retinopathy. Atypical cases have been described, such as venous or arterial occlusions, ischemic neuropathy, and for the first time in our series a case of inaugural bilateral central retinal artery occlusion.Conclusion Takayasu arteritis should be considered in young patients with atypical vascular or inflammatory retinal manifestations. Collaboration with internists is mandatory in order to diagnose systemic involvement and propose the best therapeutic approach.

Proliferating Immature Schwann Cells Contribute to Nerve Regeneration After Ischemic Peripheral Nerve Injury

Schwann cells exhibit a high degree of plasticity in adult peripheral nerves after mechanical injury; they have, therefore, been implicated in promoting nerve regeneration. However, Schwann cell behavior after ischemic injury has not yet been elucidated. To determine how Schwann cell plasticity may contribute to recovery from ischemic neuropathy, we used a rat model in which ischemia was induced in the tibial nerve by a 5-hour occlusion of the supplying arteries. Proliferation of immature Schwann cells that emerged in the injured nerve was evaluated by double immunostaining for the p75 neurotrophin receptor and proliferating cell nuclear antigen. The number of proliferating cell nuclear antigen/p75 neurotrophin receptor double-positive cells increased significantly in 1 to 2 weeks after ischemia and subsequently decreased by 4 weeks. During this time, the postmitotic Schwann cells differentiated into mature cells, as demonstrated with bromodeoxyuridine incorporation, which facilitated axon guidance and subsequent axon remyelination. These results suggest the emergence and proliferation of immature Schwann cells that contribute to nerve regeneration after ischemic injury. The manipulation of this population of proliferating immature Schwann cells may be a useful strategy for treating ischemic peripheral neuropathy.

Nerve growth factor: Does this have the potential to become a miraculous treatment for diabetic heart?

Nerve growth factor: Does this have the potential to become a miraculous treatment for diabetic heart?

Clinical and Electrophysiologic Characterization of Chronic and Critical Ischemic Monomelic Neuropathy after Revascularization: A Case Series (P07.151)

Objective: To assess the outcome of chronic and critical ischemic monomelic neuropathy after revascularization. Background Chronic and critical limb ischemia is a known cause of monomelic neuropathy. Although revascularization improves rest pain, objective neuropathic improvement has not been adequately studied in prospective studies. Design/Methods: A prospective study was performed in 9 patients with critical limb ischemia. The contralateral limb was used as a control. Neurologic Symptom Score (NSS – range 0-15, sensory/motor), Neurologic Examination Score (NES – range 0-52, sensory/reflexes/motor), and electrophysiologic data were available for 5 patients at baseline and 6 months post revascularization. Results: The mean improvement in NSS was 6.6/15 (44%) in the revascularized limbs compared to 1.4/15 (9%) in the control limbs (p = 0.052). The mean improvement in NES was 3/52 (6%) in the revascularized limbs compared to 0/52 (0.3%) in the control limbs (p = 0.266). The sural sensory amplitude in the revascularized limbs was unchanged in 2, worsened in 2, and improved in 1 (absent to 7.8 µV). In the control limbs, this response worsened in 2, improved in 2, and was unchanged in 1. Improvement in conduction velocities of the peroneal and tibial motor responses were greater in revascularized than control limbs. Sympathetic skin response (SSR) was absent in three affected limbs at baseline, but were recordable post revascularization in two of these limbs. In the control limbs, SSR was present in 5/5 at baseline and 4/5 at 6 months. Conclusions: Improvement of symptoms, neurologic exam findings, and sympathetic function can be seen following revascularization in patients with chronic critical ischemic monomelic neuropathy. Disclosure: Dr. Absalom has nothing to disclose. Dr. Wolfe has received personal compensation for activities with Eli Lilly & Company, Talecris and Genzyme Corporation as a speaker and/or participant on an advisory board. Dr. Nations has received personal compensation for activities with Hilton Pharmaceuticals. Dr. Nations has received research support from Genzyme Corporation. Dr. Trivedi has nothing to disclose. Dr. Muppidi has nothing to disclose.

Ischaemic monomelic neuropathy (IMN) following vascular access surgery for haemodialysis: an under-recognized complication in non-diabetics.

Ischaemic monomelic neuropathy (IMN) is an infrequently recognized type of neuropathy, produced after acute arterial occlusion or reduced blood flow to an extremity. In the upper limb, it usually occurs after vascular access surgery for haemodialysis. IMN has been reported largely in diabetics with peripheral neuropathy and atherosclerotic vascular disease. We report a case of IMN following arteriovenous (AV) fistula formation in a patient with advanced chronic renal failure, who did not have diabetes mellitus and symptoms of peripheral neuropathy or features of atherosclerotic vascular disease. Symptoms improved immediately after the distal revascularization and interval ligation procedure to the AV fistula.

RE: Diffusion MR Imaging of Postoperative Bilateral Acute Ischemic Optic Neuropathy

Dear Editor: We read with great interest, the case report on ischemic optic neuropathy (1). We would like to add a few points concerning the blood supply of the optic nerve and the correlation with the development of post-operative ischemic neuropathy. Actually, the perioperative or post-operative vision loss (postoperative ischemic neuropathy) is most likely due to ischemic optic neuropathy. Ischemic optic neuropathy (2) is classified as an anterior ischemic optic neuropathy (AION) and posterior ischemic optic neuropathy (PION). This classification is based on the fact that blood supply (2) to the anterior segment of the optic nerve (part of the optic nerve in the scleral canal and the optic disc) is supplied by short posterior ciliary vessels or anastamotic

Bilateral Ischemic Optic Neuropathy Developed under Interferon Therapy

Introduction. Interferon is a glycoprotein produced by assigned cells of immune system. It has been used in many different diseases. Although flu-like syndrome, myalgia, rash, hypotension, thrombocytopenia and peripheral neuropathy due to interferon use are encountered frequently, ocular side effects are rare, generally mild and transient. Case Report. 47-year-old female patient, presented with a mass lesion in right renal pelvis. Right radical nephrectomy was applied and the histopathological examination was consistent with papillary renal cell carcinoma. Interferon alpha treatment was started subcutaneously at the dose of 5 MIU/3 times in a week. Four weeks after the interferon therapy, suddenly bilateral visual loss developed. We discussed the diagnosis, followup, and treatment of the patient who developed irreversible ischemic optic neuropathy and had no previous known primary systemic disease to cause this condition. Conclusion. We suggest that patients should be screened for risk factors causing optic ischemic neuropathy, before interferon therapy. Although there was no adequate information in the literature for the followup, patients should be monitorized before, 1 month after, and 2 months after the treatment. And if there is no complication, we suggest that they should be followed up at 3-month intervals.

LOX-1, Oxidative Stress and Inflammation: A Novel Mechanism for Diabetic Cardiovascular Complications

Diabetes mellitus is a common metabolic disease characterized by a state of oxidative stress, inflammation and endothelial dysfunction. This malady can lead to a number of complications such as ischemic heart disease, nephropathy, neuropathy, retinopathy and impaired wound healing. The etiology of diabetic complications is multifactorial, and is closely associated with oxidative stress and inflammation. Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1), a receptor for oxidized low density lipoprotein (ox-LDL), plays critical roles in multiple signal transduction pathways and is involved in the process of oxidative stress and inflammation. Recent studies provide important insights into the roles of LOX-1 in the development and progression of diabetic vasculopathy which is the underlying mechanism of diabetic complications. In this review, we summarize mechanistic studies, mainly related to LOX-1, on the development and progression of diabetes mellitus and its cardiovascular complications.

Spontaneously Sealed Aortic Dissection Presenting with Multiple Ischemic Strokes

Based on these percentages, approximately 10% of patients present with neurologic symptoms and without chest pain. Neurologic manifestation in aortic dissection included ischemic stroke (16%), ischemic neuropathy (11%), syncope (6%), seizures (3%), hypoxic encephalopathy (2%), and spinal cord ischemia (1%).

Bilateral abducens nerve palsy by compression from bilateral anterior inferior cerebellar artery

Isolated abducens nerve palsy affects patients with various pathological conditions, including head trauma, brain tumor, and infection. Systemic conditions such as diabetes mellitus or hypertension are also risk factors for abducens nerve palsy and may cause ischemic neuropathy [1]. Furthermore, compression by vascular abnormalities such as dolichoectatic arteries or aneurysms may induce abducens nerve palsy at its long extracerebral segment [2–7]. However, bilateral cases of isolated abducens nerve palsy are rare. Such cases have been reported in patients with ruptured aneurysms of the anterior communicating [8] or vertebrobasilar artery [9, 10], bilateral intracavernous carotid artery aneurysms [7], or subarachnoid hemorrhage without aneurysm [9]. Here, we report a case of bilateral isolated abducens nerve palsy due to compression by the bilateral anterior inferior cerebellar artery (AICA). A 75-year-old man developed diplopia without ocular pain 6 months earlier. He had undergone surgeries for gastric ulcer 33 years earlier and lung adenocarcinoma 9 years earlier. Follow-up for lung cancer revealed no evidence of relapse or metastasis. Two months earlier, diplopia worsened without other symptoms. Neurological examination revealed left ptosis, which had previously been identified. Additionally, there was complete right, and moderate left, abducens nerve palsy, but no abnormalities in pupil size, light reflex, and vertical eye movement (Fig. 1a). Laboratory tests showed slightly elevated glycosylated hemoglobin Alc level (6.6%; normal range: 4.3–5.8%), but normal erythrocyte sedimentation rate and thyroid function. Anti-acetylcholine esterase antibody and edrophonium tests were negative. Cerebrospinal fluid analysis showed a mild increase in protein content (50 mg/dL) and normal cell count (1 lymphocyte/lL) without malignant cells. Positron emission tomography/computed tomography scan revealed no abnormalities. Brain magnetic resonance (MR) imaging, including with gadolinium enhancement, showed no brainstem or cavernous sinus lesions. MR angiography demonstrated dolichoectatic basilar and left vertebral arteries (Fig. 1b). MR 3D heavy T2-weighted imaging showed stretching of the right abducens nerve by the right AICA (Fig. 1c) and compression of the left abducens nerve at the point of its exit zone by the left AICA (Fig. 1d). The condition improved slightly over 4 months, and there was no evidence of focal or systemic recurrence of lung cancer at 25 months after the onset of diplopia. An anatomical study showed that the ventral surface of the abducens nerve was crossed by the AICA in 75% of autopsied brains and that, in the majority of cases, the AICA was in contact with the abducens nerve [11]. Another study showed the AICAs or their branches were in contact with it in all cases of 44 hemispheres, and pierced in 11.4% [12]. In this patient, the left vertebral artery and basilar arteries were dolichoectatic with a deviation to the right, and the bilateral abducens nerves were compressed by the A. Taniguchi (&) Y. Ii H. Tomimoto Department of Neurology, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan e-mail: a2005t@clin.medic.mie-u.ac.jp

Transient Oculomotor Palsy after Influenza Vaccination: Short Report

Several neurological complications have been described after influenza vaccination. Oculomotor palsy has not been yet related with influenza vaccine. We report a 79-year-old man who developed an acute transient right oculomotor palsy two days after a routine influenza vaccination, for which no other cause was identified. There was no evidence of diabetes, glucose intolerance, high blood pressure, hipercholesterolemia, smoking, obesity, systemic vasculitis, or other risk factor for ischemic neuropathy. The cerebrospinal fluid was normal as well as the MRI and MRA scans. The differential diagnosis and the possible relationship between the vaccine and the oculomotor palsy are discussed.

Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis

Demyelinating optic neuritis (ON) is the most common cause of optic neuropathy typically presenting with a subacute painful visual loss. In 20% of patients with multiple sclerosis (MS), ON is the presenting symptom and half of the patients with isolated ON develop MS within 15 years. The diagnosis of ON plays an important role in neurological practice. A correct and early diagnosis is necessary to ensure optimal further investigations and treatment. Other causes of optic neuropathies such as connective tissue disorders, infectious diseases, tumours or ischaemic neuropathies are less frequent but clinical and therapeutic management can differ dramatically. We present five patients admitted to our hospital with suspected demyelinating ON, but the clinical work up revealed different causes of optic neuropathy. We discuss the differential diagnosis of ON and clinical red flags that require careful diagnostic assessment of other diseases. A workflow for the diagnosis of optic neuropathies is presented.

Ischemic Monomelic Neuropathy: A Rare but Important Complication after Hemodialysis Access Placement - a Review

The creation of a vascular access for hemodialysis is a frequently performed procedure. Ischemic monomelic neuropathy (IMN) is a rare, but important complication of hemodialysis access (HA) procedures, which can lead to severe and nonreversible limb dysfunctions. Therefore, in any case of postoperative neurological malfunction, immediate neurological investigations should be undertaken. If IMN is diagnosed, improvement of distal perfusion should be established without delay. IMN is a form of hemodialysis-associated ischemic syndrome (as the so-called steal syndrome), but experiences with this complication are small. Every case of IMN should be carefully documented and if possible published, to gain more experience about this rare but important complication.

Three cases of rheumatoid arthritis with laryngeal stridor

The purpose of this is case-based review is to report a series of patients with rheumatoid arthritis who developed stridor and highlight this potentially life-threatening manifestation of the disease. We report three cases from the Rheumatology Department of University College Hospital, London and review the literature on the prevalence, clinical presentation, histopathological features and treatment of laryngeal involvement in rheumatoid arthritis. In two patients, emergency tracheostomy was necessary to maintain a patent airway. One patient improved with systemic corticosteroids without the need for surgical intervention. All patients were seropositive with anti-CCP antibodies and had long-standing erosive disease. Stridor in patients with rheumatoid arthritis is typically due to arthritis of the cricoarytenoid joints leading to fixation of the vocal cords in a midline position. Cricoarytenoid joint arthritis may be acute, chronic, or acute-on-chronic. Emergency tracheostomy may be life-saving in cases of acute stridor. Cricoarytenoid inflammation and airway compromise may respond to local or systemic corticosteroid therapy. Other causes of vocal cord paresis in rheumatoid arthritis include ischaemic neuropathy of the recurrent laryngeal and vagus nerves due to vasculitis or cervicomedullary compression due to rheumatoid involvement of the cervical spine.

Anterior ischemic optic neuropathy after conventional coronary artery bypass graft surgery – a case report

SummaryBackgroundPerioperative optic neuropathy is a disease which can lead to serious, irreversible damage of vision. This complication could be the result of non-ocular surgery, for example, cardiac or spinal procedures.We present a case of anterior ischemic neuropathy (AION) which occurred following a conventional coronary artery bypass graft procedure.Case ReportA 57-year-old man, 4 days after Conventional Coronary Artery Bypass Graft surgery as result of multi-vessel stabile coronary artery disease and history of anterolateral wall myocardial infarction, was admitted to the Eye Clinic due to significant loss of vision in his right eye. The patient had hypertension and was a heavy smoker. On admission, the slit lamp examination revealed a relative afferent pupillary defect in the right eye. The fundus examination showed optic disc edema with the presence of flame hemorrhages. Best corrected visual acuity (BCVA) was 0.02. The results of eye examination and fluorescein angiography confirmed the diagnosis of AION. Anti-aggregation and antithrombotic treatment was continued with steroids and vasodilators. After 7 days of this treatment we noticed the improvement of BCVA to 0.2. At 6-month follow-up, the vision was stable, and fundus examination revealed optic disc atrophy.ConclusionsAfter cardiac surgical operations, such as coronary artery bypass graft procedures, anterior ischemic optic neuropathy may occur. In those cases, close cooperation between the various specialists is necessary.

Ischemic Neuropathy Associated with Livedoid Vasculitis

BackgroundLivedoid vasculitis is a chronic dermatological problem with an unclear etiology. Clinical findings are petechiae with painful ulcers in both lower extremities, which heal to become hyperpigmented and porcelain-white satellite lesions. There are only a few reported cases of livedoid vasculitis presenting in combination with peripheral neuropathy.Case ReportWe report the first case of a Korean patient presenting with mononeuritis multiplex combined with livedoid vasculitis, which was confirmed by electrophysiological and pathological studies.ConclusionsOur report supports the possible vaso-occlusive etiology of livedoid vasculitis in multifocal ischemic neuropathy.

Artificial control of blood-nerve barrier: a novel therapeutic approach to peripheral neuropathies

Blood-nerve barrier (BNB) is a "Janus-faced" structure for the peripheral nerve parenchyma. Healthy BNB may contribute to stabilize the internal milleu of peripheral nervous system (PNS) and to stop the entrance of toxic substances and harmful leukocytes into nerve parenchyma. On the other hand, healthy BNB may sometimes be a drawback because the peripheral nerve parenchyma cannot receive enough amount of nutrients and growth factors and cannot excrete toxic substances into systemic circulation because of its presence. Here we present a future therapeutic strategy to control BNB function, based on the basic knowledge acquired from recently developed human immortalized cell lines of BNB origin. If we can artificially regulate the BNB permeability and the expression of adhesion molecules on the surface of BNB-forming endothelial cells, and stop the entrance of toxic substances as well as pathogenic leukocytes into PNS parenchyma, the treatment of inflammatory neuropathies may make great progresses. For hereditary, metabolic and ischemic neuropathies, the promotion of the entrance of growth factors into PNS parenchyma and of the excretion of toxic substances should powerfully encourage the regeneration of axons.

Human being needs a revolution on diabetes therapy

Diabetes mellitus (DM) is a group of metabolic diseases associated with hyperglycemia. The main problem is insufficient insulin production in pancreas β-cells (Type 1 DM) or insensitivity (or resistance) of the tissues to insulin (Type 2 DM). Type 2 DM (T2DM) is the most common type of DM. T2DM is typically associated with obesity, sedentary lifestyle, old age, family history of diabetes, and ethnicity. Diabetes mellitus is the most common endocrine disorder currently affecting over 170 million people worldwide. In 2030, it is predicted that 360 million people will suffer from this disease. Especially T2DM is rapidly emerging as one of the greatest global health problems of the 21st Century. As a consequence, it is expected that a rise in the complications associated with diabetes, such as ischemic heart disease, stroke, neuropathy, retinopathy, and nephropathy, will be triggered. Chronically-elevated blood glucose is not only important in diabetes but also several other chronic diseases including metabolic syndrome, obesity, and cardiovascular disorders. Therefore, ...

MRI of the eye muscles in a case of ophthalmoplegia caused by common carotid artery occlusion suggests ischemic myopathy

Ocular muscle palsies following carotid artery disease is thought to be caused by ischemia of the cranial oculomotor nerves but it may also be due to ischemia of the extraocular muscles (EOM). We studied a patient with common carotid artery occlusion syndrome (CCAOS) to elucidate the two competing hypotheses. MRI and sonography of the orbita showed oedematous swelling of all left EOM. MRI short-tau inversion recovery (STIR) sequences showed hyperintensities and a prolonged T2-relaxation time in EOM indicating muscle oedema. It decreased within two weeks as ophthalmoplegia improved. For several reasons ischemic EOM myopathy rather than ischemic neuropathy seems to be the morphological correlate of ophthalmoplegia after ipsilateral CCAOS in this patient.