Management Of Neurological Complications Research Articles

Darier disease is associated with neurodegenerative disorders and epilepsy

Darier disease (DD) is a rare monogenetic skin disorder with limited data on its potential association with neurological disorders. This study aimed to investigate the association between DD and neurological disorders, specifically Parkinson's disease, dementias, and epilepsy. Using Swedish national registers in a period spanning between 1977 and 2013, 935 individuals with DD were compared with up to 100 comparison individuals each, randomly selected from the general population based on birth year, sex, and county of residence at the time of the first diagnosis of DD. Individuals with DD had increased risks of being diagnosed with Parkinson's disease (RR 2.1, CI 1.1; 4.4), vascular dementia (RR 2.1, CI 1.0; 4.2), and epilepsy, (RR 2.5, CI 1.8; 3.5). No association of DD with other dementias were detected. This study demonstrates a new association between DD and neurodegenerative disorders and epilepsy, underlining the need for increased awareness, interdisciplinary collaboration, and further research to understand the underlying mechanisms. Early identification and management of neurological complications in DD patients could improve treatment strategies and patient outcomes. The findings also highlight the role of SERCA2 in the pathophysiology of neurological disorders, offering new targets for future research and potentials for novel treatments.

Management of Neurologic Complications in Patients with Brain and Spine Tumors.

Patients with brain and spine tumors represent a distinct population with unique needs. We provide a practical review of neurologic care in this group with an emphasis on familiarizing the general neurologist to the nuances of neuro-oncologic supportive care. We review the management of cerebral edema, steroid dosing, and pertinent side effects. We discuss seizure management, including choice of anticonvulsants, putative antitumor effects, and important seizure mimics like drop attacks. We review the presentation and symptomatology of stroke-like migraine attack after radiation therapy (SMART syndrome). We describe the signs and symptoms that should prompt concern for metastatic spinal cord compression, as well as both acute and definitive treatment options. Finally, we discuss the underappreciated incidence of venous thromboembolic events, particularly in patients with gliomas, and review the data on management.

Neurologic Complications in Patients With Left Ventricular Assist Devices.

Left ventricular assist device (LVAD) use has revolutionised the care of patients with advanced heart failure, allowing more patients to survive until heart transplantation and providing improved quality for patients unable to undergo transplantation. Despite these benefits, improvements in device technology, and better clinical care and experience, LVADs are associated with neurologic complications. This review provides information on the incidence, risk factors, and management of neurologic complications among LVAD patients. Although scant guidelines exist for the evaluation and management of neurologic complications in LVAD patients, a high index of suspicion can prompt early detection of neurologic complications which may improve overall neurologic outcomes. A better understanding of the implications of continuous circulatory flow on systemic and cerebral vasculature is necessary to reduce the common occurrence of neurologic complications in this population.

Spectrum of computed tomography (Ct)-brain findings in Covid-19 patients with CNS manifestations

Background: Infection with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) results in Corona Virus Disease 2019 (COVID -19) predominantly it affects respiratory system; however it has become apparent that many other organ systems including central nervous system can also be involved. Imaging plays an essential role in diagnosis of all manifestations of the disease and its complications. Objective: To study the spectrum of neuro-imaging findings on CT in COVID-19 patients with CNS symptoms. Material and Methods: Non-contrast CT scan of brain was done in 80 patients of either gender having COVID-19, confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) with CNS manifestations. Images were assessed for presence of abnormal findings like Infarcts, hemorrhage, venous/arterial thrombosis, leukoencephalopathy, white matter disease, hypoxic ischemic injury, encephalitis and posterior reverse encephalopathy syndrome. Results: A total of 80 patients with COVID-19 were reviewed, out of which CT was abnormal in 35 patients (43.7%). findings included various types of infarcts, intra and extra axial haemorrhages, Diffuse axonal injury and PRES (Posterior Reversible Encephalopathy Syndrome). Our study demonstrated that the neurological imaging of patients with COVID-19 were variable without a specific pattern but is dominated by ischemic infarcts and intracranial haemorrhages. Conclusion: C0VID-19 is a serious public health crisis and can have neurological manifestations, therefore these patients should be evaluated early for neurological symptoms as timely analysis and management of neurological complications are key to improving the prognosis.

COVID-19 and Hepatic Encephalopathy: A Narrative Review

The 2019 novel coronavirus (COVID-19) has been known as a highly pandemic virus that is characterized by a severe multiorgan pathology. Generally, cardio-respiratory complications are the dominant manifestations in patients infected with COVID-19. Since the coronavirus targets angiotensin-converting enzyme (ACE) receptors, however, the virus is also likely to exhibit multiorgan complications. Some retrospective cohorts as well as case studies have shown varying degrees of increased alanine transaminase (ALT)/aspartate transaminase (AST) in COVID-19 infections. A limited number of histopathological studies examining the liver have also reported an acute portal necrosis of this organ. Some other studies investigating the patients with COVID-19 have documented an acute hepatic encephalopathy with altered mental status. Beyond doubt, having a greater awareness of these complications positively contributes to timely and effective management and treatment of the patients. The present review article, therefore, aimed to highlight the consequences of developing hepatic encephalopathy for patients with COVID-19, its possible multifaceted mechanisms, and the management of neurological complications in these infected patients.

This Month in Anesthesiology

This Month in Anesthesiology

CEREBRAL ABSCESS AND MYCOTIC ANEURYSM AS A CONSEQUENCE OF INFECTIVE ENDOCARDITIS: A CASE REPORT

Background: Neurological complications of infective endocarditis are common and can cause significant morbidity and mortality. A broad spectrum of neurological manifestations may be observed. This case is used to show an approach towards the management of neurological complication of bacterial endocarditis based on a review of the published work. Case Presentation: A 26-year-old male patient was admitted to our department with sudden onset of left side weakness associated with aphasia and an intense headache. Clinical assessment showed an infective endocarditis with two mobile vegetations attached to the mitral valve complicated by an intracranial mycotic aneurysm and a brain abscess. The patient was managed only with antibiotic therapy on the decision of a multidisciplinary team, with an excellent clinical outcome. Conclusions: The management of neurologic complications of infective endocarditis remains challenging given the lack of prospective, controlled studies. Therefore, the decision process requires the participating of a multidisciplinary team.

A Rare Case of COVID-19-Associated Acute Hemorrhagic Necrotizing Encephalopathy in a Young Patient

Coronavirus disease-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2, a strain of coronavirus. It can also present with neurological sequelae. It has been related to intracranial cytokine storm. Here, we present a case of acute hemorrhagic necrotizing encephalopathy in a young patient who presented with the characteristic magnetic resonance imaging findings. As the pandemic continues, we can expect that the spectrum of neurological presentations will widen. Knowledge of these neuroimaging features may assist in the detection and early management of neurological complications.

Postoperative Management of Lung Transplant Recipients in the Intensive Care Unit.

The number of lung transplantations is progressively increasing worldwide, providing new challenges to interprofessional teams and the intensive care units. The outcome of lung transplantation recipients is critically affected by a complex interplay of particular pathophysiologic conditions and risk factors, knowledge of which is fundamental to appropriately manage these patients during the early postoperative course. As high-grade evidence-based guidelines are not available, the authors aimed to provide an updated review of the postoperative management of lung transplantation recipients in the intensive care unit, which addresses six main areas: (1) management of mechanical ventilation, (2) fluid and hemodynamic management, (3) immunosuppressive therapies, (4) prevention and management of neurologic complications, (5) antimicrobial therapy, and (6) management of nutritional support and abdominal complications. The integrated care provided by a dedicated multidisciplinary team is key to optimize the complex postoperative management of lung transplantation recipients in the intensive care unit.

Neurological and Systemic Manifestations of Severe Scorpion Envenomation.

Scorpion envenomation is a life-threatening toxicological emergency and considered as a major public health problem, especially in endemic regions (India, Africa, Latin America); it is generally characterized by low resources and tropical or subtropical weather. Scorpion envenomation is especially fatal in the first hours, usually due to respiratory and/or cardiovascular collapse. The neurologic manifestations, triggered by multiple neurotoxic mechanisms, are varied and complex and mostly reported in children. The aim of this review is to clarify the epidemiologic characteristics and clinical manifestations as well as diagnosis and management of neurologic complications following scorpion envenomation. The management of patients with severe clinical forms is based on early recognition of the sting, antivenom serum administration, and cardiorespiratory and systemic support.

Neurological Complications in Patients with Heart Transplantation.

Neurological complications after heart transplantation are common and include cerebrovascular events (ischemic strokes, hemorrhagic strokes, and transient ischemic attacks), seizures, encephalopathy, central nervous system (CNS) infections, malignancies, and peripheral nervous system complications. Although most neurological complications are transient, strokes and CNS infections can result in high mortality and morbidity. Early recognition and timely management of these serious complications are crucial to improve survival and recovery. Diagnosing CNS infections can be challenging because their clinical presentation can be subtle in the setting of immunosuppression. Immunosuppressive medications themselves can cause a broad spectrum of neurological complications including seizures and posterior reversible encephalopathy syndrome. This article provides a review of the diagnosis and management of neurological complications after cardiac transplantation.

Neurological Complications of Sturge-Weber Syndrome: Current Status and Unmet Needs

ObjectiveWe aimed to identify the current status and major unmet needs in the management of neurological complications in Sturge-Weber syndrome. MethodsAn expert panel consisting of neurologists convened during the Sturge-Weber Foundation Clinical Care Network conference in September 2018. Literature regarding current treatment strategies for neurological complications was reviewed. ResultsAlthough strong evidence-based standards are lacking, the implementation of consensus-based standards of care and outcome measures to be shared across all Sturge-Weber Foundation Clinical Care Network Centers are needed. Each patient with Sturge-Weber syndrome should have an individualized seizure action plan. There is a need to determine the appropriate abortive and preventive treatment of migraine headaches in Sturge-Weber syndrome. Likewise, a better understanding and better diagnostic modalities and treatments are needed for stroke-like episodes. As behavioral problems are common, the appropriate screening tools for mental illnesses and the timing for screening should be established. Brain magnetic resonance imaging (MRI) preferably done after age one year is the primary imaging modality of choice to establish the diagnosis, although advances in MRI techniques can improve presymptomatic diagnosis to identify patients eligible for preventive drug trials. ConclusionWe identified the unmet needs in the management of neurological complications in Sturge-Weber syndrome. We define a minimum standard brain MRI protocol to be used by Sturge-Weber syndrome centers. Future multicenter clinical trials on specific treatments of Sturge-Weber syndrome-associated neurological complications are needed. An improved national clinical database is critically needed to understand its natural course, and for retrospective and prospective measures of treatment efficacy.

Neurologic Complications of Fat Embolism Syndrome.

Fat embolism syndrome (FES) is a rare disorder with potentially devastating neurologic complications. This article reviews the history, pathophysiology, clinical features, diagnosis, and treatment of FES with a focus on its neurologic aspects. The neurologic complications of FES are more commonly recognized with current diagnostic testing and increase awareness of the disorder. FES may present initially with neurologic manifestations. Prompt diagnosis of FES and of its neurologic manifestations could be lifesaving. This includes respiratory support and management of neurological complications. The classic clinical triad of pulmonary insufficiency, neurologic disturbances, and petechial skin rash typically presents 24 to 72h following an initial insult, most commonly a traumatic long bone fracture. Early onset (< 24h) and delayed onset (> 72h) have been described. Neurologic manifestations may include ischemic/hemorrhagic strokes, retinal ischemia, seizures, autonomic dysfunction, and diffuse brain injury. Diagnosis remains clinical. Management consists mainly of supportive care.

NEUROLOGICAL COMPLICATIONS OF REGIONAL ANESTHESIA

In the review, neurological complications associated with regional anesthesia are discussed: epidural hematoma (frequency 0.0008 to 0.2%), spinal cord or peripheral nerves injury during puncture or catheter placement (frequency from 0.5 to 1%), post-dural puncture headache (frequency from 0.16 to 6% in obstetrics), transient neurologic syndrome (frequency from 0 to 37%, most often after spinal anesthesia with lidocaine), Horner’s syndrome (frequency from 0.13 to 2.5%). Epidemiology, risk factors, preventive measures, and management of neurological complications associated with regional anesthesia are presented.

Paraplegia Following Epidural Steroid Injection

Paraplegia following epidural steroid injection is, fortunately, an exceedingly rare complication. The differential diagnosis includes epidural hematoma, spinal cord injury/infarction, epidural abscess, and conversion disorder. Less likely diagnoses include worsening of underlying pathology, a new compressing lesion, or subarachnoid injection. The artery of Adamkiewicz enters the spinal canal via the neural foramen and provides blood supply to the lower two thirds of the spinal cord via the anterior spinal artery. Avoidance of the artery during a transforaminal epidural steroid injection is facilitated by entering the inferior portion of the foramen. Acute management of neurologic complications arising from an epidural steroid injection is facilitated by rapid identification of etiology. In the case of epidural hematoma, avoidance of permanent deficit is more likely when patients undergo prompt decompression. The role of intravenous steroids in acute spinal cord injury is controversial. Chronic management includes extensive rehabilitation, including physical and occupational therapy. Treatment of musculoskeletal nociceptive pain, such as due to shoulder overuse, and neuropathic pain is vital to optimize the patient’s participation in rehabilitative therapy. Keywords: Epidural Steroid Injection; Complications; Spinal Cord Injury; Epidural Hematoma; Epidural Abscess; Artery of Adamkiewicz; Anterior Spinal Artery Syndrome; Particulate Steroid; Fluoroscopic Guidance

Neurological Complications of Pediatric Cancer.

Neurologists are often consulted for diagnosis and management of neurologic complications in patients undergoing therapy for cancer. Pediatric patients with cancer, often undergoing the same types of therapy as adults with cancer, may experience different adverse events. The set of neurologic complications in children differs from that in adults and the neurologist must take into account the continuing growth and development of the patient as well as significant differences in primary diagnosis across the population. Correctly recognizing complications and initiating prompt treatment may reduce pain and prevent further progression and permanent deficits. Herein, we review the most recent literature on the neurological complications of cancer therapy organized by frequency in the pediatric population.

Neurological complications in obstetric regional anesthetic practice

Each year in the United Kingdom, nearly one-third of women giving birth will receive a central neuraxial block (CNB). The majority of postpartum neurological complications are secondary to intrinsic obstetric palsies. Despite this, neurological injury can occur following obstetric regional anesthesia. Any postpartum neurological deficit identified by the patient, anesthetist, midwife, or obstetrician should be investigated thoroughly. Prompt recognition and appropriate management of neurological complications is of the utmost importance in reducing the risk of permanent impairment. Anesthetists must recognize and coordinate the appropriate initial management for the complications associated with CNB in order to prevent permanent neurological damage.

Neurological Complications Following Pediatric Liver Transplant

We studied neurological complications (NCs) after liver transplantation (LT) in children. We performed an institutional review board-approved retrospective review of patients with LT ≤21 years during a period of 30 years (1980-2010). NCs were classified as early (within 3 months post-LT) and delayed (beyond 3 months post-LT). Of 65 children with LT, 20 (30.7%) had NCs; 16 were girls. Mean age was 11.8±5.9 years. Early NCs were found in 13.8% (9/65) of the patients: seizures in 7 and encephalopathy in 2. Abnormal neuroimaging findings were posterior reversible leukoencephalopathy syndrome (1), intracranial hemorrhage (1), mild cerebral edema (1), and bilateral basal ganglia T1W hyperintensities in magnetic resonance imaging (1). On follow-up, there were 3 deaths (unrelated to NCs). One with intracranial hemorrhage had residual hemiparesis and was taking a long-term antiepileptic drug. Late NCs are found in 16.9% (11/65) of the patients: seizures in 4, headache in 4, encephalopathy in 3 (1 had seizures in addition), and paresthesias caused by possible small-fiber neuropathy in 1. Abnormal neuroimaging findings were hypoxic-ischemic encephalopathy (1), encephalomalacia caused by old hemorrhage (1), and hyperintensity of the posterior periventricular white matter in magnetic resonance imaging (1). On follow-up, all of the patients survived; 1 had papilledema with secondary optic atrophy requiring optic nerve sheath fenestration and 1 needed long-term antiepileptic drug. NCs are common in children after LT, seizures being the most common. In contrary to the previous studies, we found delayed complications more often than early complications. Early detection and appropriate management of NCs is important.

Primary Central Nervous System Lymphoma

Management goals for patients with primary central nervous system lymphoma (PCNSL) include long-term disease control, management of neurologic complications, and preservation of neurocognitive function. Various treatment options can achieve several of these goals. Chemotherapy as monotherapy or as combination therapy has emerged as the cornerstone of therapy for patients with newly diagnosed PCNSL. Outside of a clinical trial, patients with newly diagnosed PCNSL should receive high-dose intravenous methotrexate (MTX) as a single agent or as part of a combination regimen with radiation therapy reserved for relapse. The regimen should have an adequate MTX dose (>3g/m(2)) to reach cytotoxic concentrations in the cerebrospinal fluid (CSF) to treat occult leptomeningeal disease (LMD). Alternative modes of chemotherapy delivery for selected patients, preferably in the context of a clinical trial, include high-dose chemotherapy with autologous stem cell rescue and intra-arterial chemotherapy with blood-brain barrier disruption. Whole brain radiation therapy (WBRT) in standard doses and fractionation carries an unacceptable rate of long-term neurocognitive toxicity. However, lower doses in daily divided fractions may offer the possibility of adding this modality with preservation of cognition but should be performed only in the context of a clinical trial. The long-term efficacy and toxicity of this approach is currently under investigation. Certain presentations of PCNSL require different strategies. Patients with ocular lymphoma at diagnosis should receive high-dose MTX as this drug can reach cytotoxic intravitreal concentrations. Recurrence in the eyes is managed with intravitreal chemotherapy including MTX or rituximab or with radiation therapy. The field of treatment (eyes vs whole brain) should be individualized. Intrathecal (IT) MTX should be included in the treatment regimen for those patients with a positive CSF cytology, or in regimens in which lower doses of MTX are delivered over longer periods of time. It is probably reasonable to withhold IT chemotherapy in those patients who have no detectable subarachnoid disease and who can receive higher doses of MTX (>3g/m(2)) over shorter infusion periods (2-4h). Patients who develop leptomeningeal involvement despite high- dose MTX can be managed with IT chemotherapy such as liposomal cytarabine or MTX or even rituximab. Areas of bulky or symptomatic LMD should probably be treated with radiation therapy as well. Because PCNSL is an uncommon disease, entry into clinical trials must be pursued to advance the state of the art.

Prevention and management of neurological complications after scoliosis surgery

Neurologic complications are rare but devastating events after scoliosis surgery;a thorough preoperative work-up and effective intraoperative monitoring of the spinal cord may reduce the incidence.This review discusses the incidence,preoperative work-up,intraoperative monitoring,and managing strategies for neurologic complications of scoliosis surgery.