Mild Neurological Deficits Research Articles

Utility of Items of Baseline National Institutes of Health Stroke Scale as Predictors of Functional Outcomes at Three Months after Mild Ischemic Stroke

Predicting outcomes of acute stroke patients initially presenting with mild neurologic deficits is crucial in decision making regarding thrombolytic therapy. We examined the utility of individual National Institutes of Health Stroke Scale (NIHSS) score items or clusters of items as predictors of functional outcomes at 3 months after mild stroke. Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had baseline NIHSS scores less than or equal to 5. Functional outcomes at 3 months were dichotomized as favorable (modified RankinScale [mRS] score 0 or 1) or unfavorable (mRS 2-6). Individual NIHSS items, clusters of items, and the total score were tested for their ability to predict outcomes in multivariable models. Area under the receiver operating characteristic curve (AUC) was used to assess model performance. Of the 2209 patients who met eligibility criteria, 588 (26.6%) exhibited unfavorable functional outcomes at 3 months. Of the 15 items of the NIHSS, all except item 8 (sensory) and item 11 (extinction) were significantly associated with unfavorable functional outcomes in bivariate analysis (P's < .05). Among the multivariable models, the model with the total NIHSS score exhibited an AUC similar to that of the model with all NIHSS items in predicting functional outcomes (.758 [95% confidence interval .739-.775] versus .759 [.740-.776]; P = .75 for pairwise comparison). Simply using the total NIHSS score was as effective as using all individual items in predicting outcomes of mild stroke patients.

The PHES battery does not detect all cirrhotic patients with early neurological deficits, which are different in different patients.

Background and aimsThe psychometric hepatic encephalopathy score (PHES) is the “gold standard” for minimal hepatic encephalopathy (MHE) diagnosis. Some reports suggest that some cirrhotic patients “without” MHE according to PHES show neurological deficits and other reports that neurological alterations are not homogeneous in all cirrhotic patients. This work aimed to assess whether: 1) a relevant proportion of cirrhotic patients show neurological deficits not detected by PHES; 2) cirrhotic patients with mild neurological deficits are a homogeneous population or may be classified in sub-groups according to specific deficits.MethodsCirrhotic patients “without” (n = 56) or “with” MHE (n = 41) according to PHES and controls (n = 52) performed psychometric tests assessing attention, concentration, mental processing speed, working memory and bimanual and visuomotor coordination. Heterogeneity of neurological alterations was analysed using Hierarchical Clustering Analysis.ResultsPHES classified as “with” MHE 42% of patients. Around 40% of patients “without” MHE according to PHES fail two psychometric tests. Oral SDMT, d2, bimanual and visuo-motor coordination tests are failed by 54, 51, 51 and 43% of patients, respectively. The earliest neurological alterations are different for different patients. Hierarchical clustering analysis shows that patients “without” MHE according to PHES may be classified in clusters according to the tests failed. In some patients coordination impairment appear before cognitive impairment while in others concentration and attention deficits appear before.ConclusionsPHES is not sensitive enough to detect early neurological alterations in a relevant proportion of cirrhotic patients. Oral SDMT, d2 and bimanual and visuo-motor coordination tests are more sensitive. The earliest neurological alterations are different in different cirrhotic patients. These data also have relevant clinical implications. Patients classified as “without MHE” by PHES belonging to clusters 3 and 4 in our study have a high risk of suffering clinical complications, including overt HE and must be diagnosed and clinically followed.

Prehospital path in acute stroke.

Too few patients with acute stroke receive thrombolytic therapy owing to the limited time window for treatment and prehospital delay. The purpose of this study is to describe the prehospital path for patients with acute stroke and, in particular, what distinguishes patients who contact the Emergency Medical Communication Centre (EMCC) from those who contact their general practitioner (GP) or Out-of-hours (OOH) services. Patients with acute cerebral infarction and intracerebral haemorrhage admitted to the Stroke Unit, Department of Neurology, Akershus University Hospital, were included. Data on the prehospital path (prehospital delay, medical contacts) were collected over the period 15 April 2009 – 1 April 2010. A total of 299 patients were included in the study. The median age was 75 years and 48.5 % were women. In all, 63.9 % of patients with acute stroke called the EMCC, and 93.7 % of these were taken directly to hospital by ambulance. Of those who called the GP’s office or OOH services, 60.7 % were asked to go to the GP’s office or OOH services in person. Patients who called and attended the GP’s office or OOH services had milder neurological deficits (p < 0.001) and longer patient delay (p = 0.018) than those who called the EMCC. Six out of ten patients who contacted the primary health care services were asked to go to the GP’s office/OOH services in person, which resulted in unnecessary delay. The findings from this study may indicate a need for specific training of this group of health care professionals in the prompt handling of patients with possible stroke.

OP10. DAY-CASE IMAGE-GUIDED BIOPSY FOR BRAIN TUMOURS: A DECADE OF EXPERIENCE

ABSTRACT: In the United Kingdom widespread adoption of day-case image-guided biopsy (DIB) for brain tumour has not occurred. To qualify for DIB patients are selected in the outpatient clinic and day-case is defined as arriving and being discharged from hospital on the same day. Discharge is allowed providing patients have no new neurology, are ambulant, have eaten, drunk passed urine, and have no significant pathology on their 4-hour postoperative CT head (CTH). Here we review a decade of experience within a single department. MATERIAL AND METHODS: Published protocols and procedures for DIB of brain tumours were used (1). All patients were under the care of a neurosurgeon with a specialist interest in neuro-oncology (JD & PLG). All Patients undergoing an image-guided biopsy for tumour were retrospectively identified from operative logbooks (October 2006 - March 2016 inclusive), and information recorded from online records or notes. RESULTS: In this 9.5 year study, 645 image-guided biopsies for tumour were performed of which 355 (55%) cases were planned DIB of a supratentorial tumour. Histological diagnosis included high grade glioma (62%), low grade glioma (18%), lymphoma (8%), metastasis (5%), meningioma (1%), primitive neuroectodermal tumour (1%), other (2%) and no diagnosis (3%). 92% of DIB patients were successfully discharged at 6 hours postoperatively. 16/355 (4.5%) of DIB patients were directly admitted following identification of a postoperative haematoma greater than 2 cm diameter on CTH. 9/16 had no associated new neurological deficit and were discharged the following day. 3/355 (0.8%) required surgical evacuation of the haematoma. 3/355 (0.8%) experienced a generalised tonic clonic seizure (GTCS) prior to discharge at 6 hours, one patient also had an associated drug reaction requiring a stay on intensive care (Duration Inpatient Stay (DIS): 2–11 median 2 days). 6/355 (2%) experienced a new mild focal neurological deficit, however were suitable for discharge home within 1–2 days, median 2. 8/355 (2%) patients were discharged home after 6 hours and later readmitted between 1–14 days post biopsy: 1 with imbalance and confusion (readmission day 1), 4 with GTCS (readmission day 1, 2, 8, 14), 1 with steroid induced psychosis (d5), 1 developed staphylococcus aureus wound infection requiring wound debridement in theatre (d8). 1 patient experienced serosanguinous wound leak and attended the ward for re-suturing. (DIS: range 0–3, median 1.5 days). DISCUSSION: DIB surgery with close clinical and radiological surveillance is well-tolerated, safe and feasible. 0.3% DIB were complicated by infection. 0% experienced significant permanent neurological deficit that influenced further oncological treatment. 0.8% of patients required further surgery due to postoperative haematoma however all made a full recovery. 3% of cases were non diagnostic on first biopsy. 1/355 CTH identified an asymptomatic extradural requiring evacuation that otherwise would have been discharged home at 6 hours post DIB. 0.8% of patients were readmitted within 48 hours of biopsy and none of our patients came to harm as a result of being a DIB. We advocate this concept is more widely adopted. Reference 1. Grundy P.L et al (2008) Br. J. Neurosurg (22) 360–367.

Lumbar herniated disc: spontaneous regression.

BackgroundLow back pain is a frequent condition that results in substantial disability and causes admission of patients to neurosurgery clinics. To evaluate and present the therapeutic outcomes in lumbar disc hernia (LDH) patients treated by means of a conservative approach, consisting of bed rest and medical therapy.MethodsThis retrospective cohort was carried out in the neurosurgery departments of hospitals in Kahramanmaraş city and 23 patients diagnosed with LDH at the levels of L3−L4, L4−L5 or L5−S1 were enrolled.ResultsThe average age was 38.4 ± 8.0 and the chief complaint was low back pain and sciatica radiating to one or both lower extremities. Conservative treatment was administered. Neurological examination findings, durations of treatment and intervals until symptomatic recovery were recorded. Laségue tests and neurosensory examination revealed that mild neurological deficits existed in 16 of our patients. Previously, 5 patients had received physiotherapy and 7 patients had been on medical treatment. The number of patients with LDH at the level of L3−L4, L4−L5, and L5−S1 were 1, 13, and 9, respectively. All patients reported that they had benefit from medical treatment and bed rest, and radiologic improvement was observed simultaneously on MRI scans. The average duration until symptomatic recovery and/or regression of LDH symptoms was 13.6 ± 5.4 months (range: 5−22).ConclusionsIt should be kept in mind that lumbar disc hernias could regress with medical treatment and rest without surgery, and there should be an awareness that these patients could recover radiologically. This condition must be taken into account during decision making for surgical intervention in LDH patients devoid of indications for emergent surgery.

Laser interstitial thermal therapy followed by minimal-access transsulcal resection for the treatment of large and difficult to access brain tumors

OBJECTIVE Laser interstitial thermal therapy (LITT), sometimes referred to as "stereotactic laser ablation," has demonstrated utility in a subset of high-risk surgical patients with difficult to access (DTA) intracranial neoplasms. However, the treatment of tumors larger than 10 cm3 is associated with suboptimal outcomes and morbidity. This may limit the utility of LITT in dealing with precisely those large or deep tumors that are most difficult to treat with conventional approaches. Recently, several groups have reported on minimally invasive transsulcal approaches utilizing tubular retracting systems. However, these approaches have been primarily used for intraventricular or paraventricular lesions, and subtotal resections have been reported for intraparenchymal lesions. Here, the authors describe a combined approach of LITT followed by minimally invasive transsulcal resection for large and DTA tumors. METHODS The authors retrospectively reviewed the results of LITT immediately followed by minimally invasive, transsulcal, transportal resection in 10 consecutive patients with unilateral, DTA malignant tumors > 10 cm3. The patients, 5 males and 5 females, had a median age of 65 years. Eight patients had glioblastoma multiforme (GBM), 1 had a previously treated GBM with radiation necrosis, and 1 had a melanoma brain metastasis. The median tumor volume treated was 38.0 cm3. RESULTS The median tumor volume treated to the yellow thermal dose threshold (TDT) line was 83% (range 76%-92%), the median tumor volume treated to the blue TDT line was 73% (range 60%-87%), and the median extent of resection was 93% (range 84%-100%). Two patients suffered mild postoperative neurological deficits, one transiently. Four patients have died since this analysis and 6 remain alive. Median progression-free survival was 280 days, and median overall survival was 482 days. CONCLUSIONS Laser interstitial thermal therapy followed by minimally invasive transsulcal resection, reported here for the first time, is a novel option for patients with large, DTA, malignant brain neoplasms. There were no unexpected neurological complications in this series, and operative characteristics improved as surgeon experience increased. Further studies are needed to elucidate any differences in survival or quality of life metrics.

Surgical Treatment of Thoracic Myelopathy Secondary to Ossification of Ligamentum Flavum

Objectives We retrospectively studied the risk factors, clinical manifestations, radiological aspects, surgical treatment, and prognostic factors in 143 patients of thoracic ossification of ligamentum flavum (OLF). Methods A total of 143 patients who underwent surgical treatment for thoracic myelopathy secondary to OLF between 1989 and 2010 were studied retrospectively. Preoperative and postoperative neurological data were reviewed and the correlation between the variables of patient characteristics, preoperative duration of symptoms, preoperative neurological status, and the functional outcome were analyzed. The male to female ratio was 1.5:1. In total, 114 patients (79.72%) were in the 4th to 6th decade of life. Only two cases (1.4%) were of less than 20-year age group. The lower thoracic region (D9–D12) was most commonly affected (61.5%). Four patients had long segment involvement (≥7 levels) and eight patients had two separate levels of involvement. Associated fluorosis was observed in 32 patients (22.37%). All patients underwent wide decompressive laminectomy with medial one-third facetectomy and OLF was resected. The part of dura adherent to OLF or calcified is also removed with it and duroplasty done if required. The average follow-up was 5 years. Outcome In all, 86 patients (60.13%) were able to do their job with mild neurological deficit such as spasticity and impairment of joint position sense. Twenty-eight patients (19.58%) were back to some job with limitation but were independent for their routine work. Sixteen patients (11.18%) improved but still required help for their routine work while thirteen patients (9.09%) were bed-ridden at last follow-up. Most common complications observed were cerebrospinal fluid leak (7.69%), neurological deterioration (8.39%), and infection (4.89%). Five (3.4%) patients required second surgery for ossification at other level during follow-up.

Neurologic Complications of Unprotected Transcatheter Aortic Valve Implantation (from the Neuro-TAVI Trial)

Cerebral embolization during transcatheter aortic valve implantation (TAVI) can lead to a spectrum of clinically relevant manifestations, ranging from overt stroke to mild neurologic or cognitive deficits and subclinical cerebral infarcts. This study sought to determine the frequency of neurologic injury, cerebral ischemic lesions, and cognitive dysfunction in subjects undergoing contemporary commercial TAVI in the United States. Neuro-TAVR is the first prospective, multicenter study to use serial systematic neurologic and cognitive assessments and diffusion-weighted magnetic resonance imaging (at 4 ± 2days after procedure) to investigate the incidence and severity of neurologic injury after contemporary unprotected TAVI in the United States. A total of 44 consecutive patients underwent TAVI at 5 US sites. Diffusion-weighted magnetic resonance imaging lesions were detected in 94%, with a mean of 10.4 ± 15.3 lesions per subject and a median total lesion volume of 295mm3 (interquartile range 71.6 to 799.6mm3). New neurologic impairment (worsening in National Institutes of Health Stroke Scale score from baseline with new cerebral lesions) occurred in 22.6% (7 of 31) of subjects at discharge and 14.8% (4 of 27) at 30days. In addition, cognitive decrements from baseline were identified by the Montreal Cognitive Assessment in 33% (12 of 36) of subjects at discharge and 41% (13 of 32) at 30days. In conclusion, this contemporary cohort of US patients confirms that TAVI results in cerebral infarction in most patients and that 1 in 5 patients have measurable neurologic impairment and 1 in 3 patients have decrease in cognitive measures by Montreal Cognitive Assessment score after TAVI, reinforcing the need for methods to mitigate the risk of brain injury during TAVI.

Specific amino acids in HIV-1 Vpr are significantly associated with differences in patient neurocognitive status.

Even in the era of combination antiretroviral therapies used to combat human immunodeficiency virus type 1 (HIV-1) infection, up to 50% of well-suppressed HIV-1-infected patients are still diagnosed with mild neurological deficits referred to as HIV-associated neurocognitive disorders (HAND). The multifactorial nature of HAND likely involves the HIV-1 accessory protein viral protein R (Vpr) as an agent of neuropathogenesis. To investigate the effect of naturally occurring variations in Vpr on HAND in well-suppressed HIV-1-infected patients, bioinformatic analyses were used to correlate peripheral blood-derived Vpr sequences with patient neurocognitive performance, as measured by comprehensive neuropsychological assessment and the resulting Global Deficit Score (GDS). Our studies revealed unique associations between GDS and the presence of specific amino acid changes in peripheral blood-derived Vpr sequences [neuropsychological impairment Vpr (niVpr) variants]. Amino acids N41 and A55 in the Vpr sequence were associated with more pronounced neurocognitive deficits (higher GDS). In contrast, amino acids I37 and S41 were connected to measurably lower GDS. All niVpr variants were also detected in DNA isolated from HIV-1-infected brain tissues. The implication of these results is that niVpr variants alter the genesis and/or progression of HAND through differences in Vpr-mediated effects in the peripheral blood and/or the brain.

Percutaneous vertebroplasty: a new animal model

Background ContextPercutaneous vertebroplasty (PVP) is a minimally invasive surgical procedure and is frequently performed in humans who need surgical treatment of vertebral fractures. PVP involves cement injection into the vertebral body, thereby providing rapid and significant pain relief. PurposeThe testing of novel biomaterials depends on suitable animal models. The aim of this study was to develop a reproducible and safe model of PVP in sheep. Study DesignThis study used ex vivo and in vivo large animal model study (Merino sheep). MethodsEx vivo vertebroplasty was performed through a bilateral modified parapedicular access in 24 ovine lumbar hemivertebrae, divided into four groups (n=6). Cerament (Bone Support, Lund, Sweden) was the control material. In the experimental group, a novel composite was tested—Spine-Ghost—which consisted of an alpha-calcium sulfate matrix enriched with micrometric particles of mesoporous bioactive glass. All vertebrae were assessed by micro-computed tomography (micro-CT) and underwent mechanical testing.For the in vivo study, 16 sheep were randomly allocated into control and experimental groups (n=8), and underwent PVP using the same bone cements. All vertebrae were assessed postmortem by micro-CT, histology, and reverse transcription-polymerase chain reaction (rt-PCR).This work has been supported by the European Commission under the 7th Framework Programme for collaborative projects (600,000–650,000 USD). ResultsIn the ex vivo model, the average defect volume was 1,275.46±219.29 mm3. Adequate defect filling with cement was observed. No mechanical failure was observed under loads which were higher than physiological. In the in vivo study, cardiorespiratory distress was observed in two animals, and one sheep presented mild neurologic deficits in the hind limbs before recovering. ConclusionsThe model of PVP is considered suitable for preclinical in vivo studies, mimicking clinical application. All sheep recovered and completed a 6-month implantation period. There was no evidence of cement leakage into the vertebral foramen in the postmortem examination.

Abstract WP76: Utility of Individual NIH Stroke Scale Items as a Predictor of Functional Outcomes in Acute Ischemic Stroke Patients Presenting With Mild Neurologic Deficits

Introduction: Predicting outcomes of acute stroke patients initially presenting with mild neurologic deficits is important in making decision for thrombolytic therapy. Previous researches with a small sample size have failed to find specific items of NIH Stroke Scale or clinical syndromes to be predictive of functional outcome. Hypothesis: We hypothesized that certain items of the NIH Stroke Scale or their combinations would be independently associated with unfavorable functional outcome after mild stroke Methods: Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had initial NIH Stroke Scale scores ≤ 5. Functional outcomes at three months after the stroke were classified as favorable (modified Rankin Scale score [mRS] 0 to 1) or unfavorable (mRS 2-6). The individual NIH Stroke Scale items were dichotomized as absent (0) or present (≥1) for the analysis. The NIH Stroke Scale items and the total score were tested for predicting the outcomes in multivariable models adjusting for demographics and clinical characteristics. Area under the ROC curve (AUC) was used to assess the performance of multivariable models. Results: Among 2,209 patients who met the eligible criteria, 588 patients (26.6%) exhibited unfavorable functional outcome (mRS 2-6) at three months. The most frequently present items were item 10 (dysarthria, 37.5%), item 4 (facial palsy, 21.1%), item 8 (sensory, 15.0%), and items indicating limb paralysis. Among 15 items of NIH Stroke Scale, all items except for item 8 (sensory) and item 11 (extinction) were significantly associated with unfavorable functional outcomes in bivariate analysis (P &lt;0.05), and many of them remained significant in multivariable analyses. In multivariable analyses, the model including the total NIH Stroke Scale scores exhibited similar AUC (0.759; 95% CI, 0.740 -0.776; P=0.75 for pairwise comparison) compared to the model with all NIH Stroke Scale items (0.758; 0.739 - 0.775) in predicting functional outcomes after the stroke. Conclusions: Simply using the total score was as effective as using all NIH Stroke Scale items in predicting outcomes of patients presented with mild stroke symptom.

Abstract WP188: Clinical Severity and Timing of Onset for Acute Ischemic Stroke and TIA During Oral Anticoagulation Using Warfarin or Non-vitamin K Antagonist Oral Anticoagulants

Background and Purpose: In Japan, four non-vitamin K antagonist oral anticoagulants (NOACs) became available in clinical use for prevention of stroke in patients with non-valvular atrial fibrillation (NVAF) between 2011 through 2014. The aim of this study is to determine underlying characteristics and ischemic stroke/TIA features of patients taking NOACs or warfarin, a vitamin K antagonist (VKA) prior to stroke/TIA. Methods: We enrolled oral anticoagulant (OAC) users for NVAF, who were admitted to our stroke center for acute ischemic stroke/TIA between March 2011 and June 2015 (ClinicalTrials.gov Identifier: NCT02251665). Results: 381 OAC users who developed stroke/TIA were studied. Of these, 63 patients took NOACs [23 women, 77±9 years, dabigatran in 33 (7 taking higher dosage between two official ones), rivaroxaban in 22 (5), apixaban in 8 (3), edoxaban in none] and 318 took VKA (143 women, 79±8 years). There were no significant differences between NOACs users and VKA users in sex, age, CHADS2 score (median 3[IQR 2-4] vs. 3 [2-4]), history of ischemic stroke/TIA (57% vs. 51%) and prior antiplatelet use (25% vs. 24%). Admission NIHSS score tended to be lower (3 [1-15] vs. 7 [2-20], p=0.076) and discharge NIHSS score was lower (1[0-5] vs 3[1-13], p=0.032) in NOACs users. Discharge mRS (2 [1-4] vs. 3 [1-4]) and mortality during hospitalization (5% vs. 4%) were similar between two groups. A different point was timing of stroke/TIA after initiating OAC ; 6% of NOAC users developed events within 14 days and 32% within 3 months, whereas 4% and 7% of VKA users did, respectively (p&lt;0.001). Congestive heart failure tended to be more common in NOACs users developing events within 3 months than those developing events later (43% vs. 19%, p=0.070). Conclusions: NOACs users tended to show milder neurological deficits than VKA users during acute hospitalization of ischemic stroke/TIA, although discharge mRS was similar. NOACs users often developed stroke/TIA within the initial 3 months after initiating OAC, particularly between 14 days and 3 months. One would take special care of ischemic events during early months after initiating NOACs.

Serum D-dimer Levels Are Proportionally Associated with Left Atrial Enlargement in Patients with an Acute Ischemic Stroke due to Non-valvular Atrial Fibrillation

Objective Left atrial enlargement (LAE) may predispose individuals to blood stasis in atrial fibrillation (AF), and thus play a crucial role in thrombogenesis. The D-dimer level is one of the surrogate markers for a hypercoagulable state and reflects thrombus formation in AF. Since the D-dimer level reflects hypercoagulability as well as thrombus and fibrin burdens, LAE could be associated with a D-dimer elevation. However, no studies have explored this association or which factors contribute to increases in the D-dimer levels in patients with AF. Therefore, we assessed whether the serum D-dimer levels are related to the left atrial volume index (LAVI) or other vascular risk factors and also evaluated the association between the D-dimer levels and the initial stroke severity. Methods Ninety-eight consecutive patients with an acute ischemic stroke and non-valvular AF (NVAF) who were anticoagulation-naïve were enrolled, and all patients were stratified into moderate-to-severe and mild neurologic deficit groups using the National Institutes of Health Stroke Scale on admission. The association between the initial serum D-dimer levels and the LAVI was evaluated in all enrolled patients, and the serum D-dimer levels were compared between the two groups. Results The patients were classified into two groups according to the severity of the neurologic deficit. In a partial correlation coefficient analysis adjusted for confounding factors, an increase in the initial serum D-dimer levels was significantly associated with LAVI (r=0.286; p=0.027). A linear regression analysis showed that a history of peripheral artery disease was the factor most strongly associated with the serum D-dimer level (t=3.90, p<0.001), followed by LAVI (t=2.37, p=0.021) and a history of congestive heart failure (t=2.16, p=0.035). The D-dimer levels were higher in the moderate-to-severe neurologic deficit group than in the mild deficit group, but this difference was not statistically significant (4.5±7.1 vs. 1.6±2.6 mg/L, p=0.068). Conclusion The serum D-dimer levels were significantly associated with LAE in anticoagulation-naïve patients with an acute ischemic stroke and NVAF.

Changes of glucose metabolism in mouse models of intracerebral hemorrhage: 18F-FDG microPET/CT study

Objective To investigate the brain glucose metabolism with 18F-FDG microPET/CT in mouse models of intracerebral hemorrhage (ICH). Methods A total of 12 healthy adult male mice were randomly divided into sham operation group (group A, n=6) and ICH model group (group B, n=6) by simple random sampling method. The animal models were established by injecting collagenase Ⅳ into the caudate nucleus of mice. Thereafter (5.5±0.3) MBq of 18F-FDG was injected into caudal vein at 6 h, 24 h, 48 h and 3 d, 5 d, 8 d, 14 d, respectively, following anesthesia. 18F-FDG microPET/CT scans were acquired 30 min after the trace injection. SUV in the perihematomal brain tissue of ICH was measured and analyzed. Two-sample t test was used to compare SUV between groups. Results (1) Some mice had mild neurologic deficit after the sham operation in group A, while all mice had a marked neurologic deficit in group B, especially at 24 h after 18F-FDG injection. (2)After 6 h, FDG uptake in perihematomal brain tissue decreased(SUV=0.80±0.04), which significantly lower than that in the opposite side(SUV=1.10±0.04; t=2.69, P<0.05) and decreased to the minimum at 24 h(SUV=0.50±0.05). 18F-FDG uptake in perihematomal brain tissue began to increase at 3 d(SUV=1.20±0.05) and kept increasing during the 14 d observation. Compared with the group A, glucose metabolism in group B was significantly lower at each time point(t=37.67-86.60, all P<0.05). Conclusions 18F-FDG microPET/CT may dynamically reflect the changes of brain glucose metabolism in ICH mouse models. The FDG uptake in the center of ICH may disappear and the volume of hematoma with decreased uptake may shrink during the observation period. Key words: Cerebral hemorrhage; Tomography, emission-computed; Tomography, X-ray computed; Deoxyglucose; Mice

Study on the correlation of C-reactive protein level and cerebral hemorrhage prognosis

Objective To analyze the correlation of C-reactive protein level and acute cerebral hemorrhage prognosis, provide the evidence for determining the condition and prognosis. Methods 163 patients with acute spontaneous intracerebral hemorrhage met selection criteria in Yantai Economic and Technology Development Area Hospital were selected as the study objects, the CRP were detected by immunoturbidimetry in the 1 day,3 days,7 days,14 days after admission,the NIHSS were calculated,48 cases of healthy people were selected as the control group, the CRP between hemorrhage group and the healthy control group, patients with different brain hemorrhage, patients with different neurological deficit were compared. Results (1)The C-reactive protein of cerebral hemorrhage group when admission were(8.92±1.0)mg/L,the control group were(4.25±0.23)mg/L,the C-reactive protein of cerebral hemorrhage group were significantly higher than that of the control group, the difference was statistically significant,t=-3.683,P<0.01.(2)The mean serum CRP after admission admission 1,3,7,14d were(9.34±1.65)mg/L,(9.56±1.58)mg/L,(6.58±1.17)mg/L,(4.98±1.26)mg/L,the CRP was a large rise in the course of the disease 1d,3d peak, F=7.487,P<0.05,the CRP had difference between large amount of brain hemorrhage,moderate amount of brain hemorrhage,and small amount of brain hemorrhage,a large amount of patients with cerebral hemorrhage CRP levels were higher than a moderate amount of patients with cerebral hemorrhage and a small amount of patients with cerebral hemorrhage 1,3 and 7d,during which the difference was statistically significant(F=3.31,4.62,4.21,P<0.01 or P<0.05).(3)The CRP peak levels of different degrees of neurological deficits in patients with acute cerebral hemorrhage decreased in 3d,7d,14d,the CRP of 3d were higher than that in 1d,the CRP of 7,14d were lower than that in 1d,CRP levels between different neurological deficits degree of acute cerebral hemorrhage were also significantly different(F=4.29,5.32,3.62,3.21,P<0.05 or P<0.01),the CRP levels of Severe neurological deficit in 1d,3d,7d,14d were significantly higher in mild and moderate neurological deficit(t=6.567,4.241,4.010,3.511 and 4.965,3.031,3.104,3.009,P<0.05 or P<0.01). Conclusion The serum CRP levels of patients with acute cerebral hemorrhage significantly increased, the serum CRP level shows dynamic changes in the first three days of the onset of peak, the CRP levels significantly correlated with the prognosis of cerebral hemorrhage, the more severe neurological deficit, the greater the amount of cerebral hemorrhage, higher serum CRP levels. Key words: Cerebral hemorrhage; C-reactive protein; Prognosis; Correlation

Left atrial dilatation is associated with severe ischemic stroke in men with non-valvular atrial fibrillation

BackgroundIncreased left atrial volume is an independent predictive factor of first ischemic stroke and other cardiovascular events in patients with non-valvular atrial fibrillation (NVAF). However, correlations between left atrial dilatation and ischemic stroke severity or ischemic lesion pattern have not been previously reported. The aim of this study was to evaluate whether left atrial enlargement is associated with worse initial stroke severity and lesion patterns. MethodsConsecutive patients with acute ischemic stroke and NVAF who were anticoagulation-naïve were enrolled, and all patients were stratified into moderate-to-severe and mild neurologic deficit groups using the National Institutes of Health Stroke Scale (NIHSS) at admission. Left atrial diameter (LAD) and left atrial volume index (LAVI), stratified by sex, were compared between the two groups. Ischemic lesion patterns were also investigated in relation to the LAD and LAVI. ResultsA total of 98 patients were enrolled. Of these, 37 were classified as having a moderate-to-severe neurologic deficit (NIHSS≥10), and 61 were classified as having a mild neurologic deficit at admission. After adjusting for confounding factors, increases in LAD and LAVI were significantly associated with moderate-to-severe neurologic deficits, especially in men. Men in the upper two tertiles of LAD and LAVI had more severe stroke symptoms when compared with participants in the lowest tertile. In partial correlation coefficient analysis adjusted for CHA2DS2-VASc risk factors, LAD and LAVI in men were positively correlated with NIHSS score (r=0.553; p<0.001 and r=0.393; p=0.004, respectively), and LAVI in all enrolled patients was significantly correlated with NIHSS score (r=0.215; p=0.045). ConclusionIncreased LAD and LAVI were associated with worse initial neurologic deficits in anticoagulation-naïve patients with acute ischemic stroke and NVAF, especially in men. Recognition of the atrial abnormalities and effective anticoagulation may reduce thrombogenesis in NVAF.

PP08.14 – 2948: Pathogenic aspects of multiple sclerosis development in children

Objective We observed 302 children 3 months – 17 years with leukoencephalitis. Methods Etiology was verified by PCR, IFA, immunocytochemistry of cerebrospinal fluid (CSF), serum and leukocytes to herpesviruses 1–6 types (HHV-1–2, VVZ, CMV, EBV, HHV-6), tick born encephalitis virus, B. burgdorferi s.l., Parvovirus B19, Enterovirus, Rubella virus, Chlamydia spp, Mycoplasma spp. Oligoclonal bands and index of intrathecal IgG, myelin basic protein (MBP), cytokines: Interferon-γ (Ifγ), Interleukin-4 (Il4), Interleukin-10 (Il10) in SCF and blood were studied. MRI (1.5–3.0 Tesla) of cerebrum and/or spinal cord were examined. Results We observed 3 types of cause of LE – acute (56.3%), protracted (17.5%) and chronic (26.2%). In children with chronic case of LE in 44% cases we observed transformation in MS. All patients of this group were below 12 years old and in 83% cases mixt herpes viral infection was detected (EBV and HHV-6). Patients with protracted case of LE in 84% recovered with mild neurological deficit. Insufficiency of systemic interferon response Ifγ (8.9±3.4 pg/ml vs 52.9±9.8, p Conclusion Thus, inadequate immune response with Ifγ and Il10 deficit and mixt herpesvirus infection in teens is the cause of chronic LE and is a pathogenic basis of MS development.

Mechanical thrombectomy in cerebral venous thrombosis: systematic review of 185 cases.

Cerebral venous thrombosis is generally treated with anticoagulation. However, some patients do not respond to medical therapy and these might benefit from mechanical thrombectomy. The aim of this study was to gain a better understanding of the efficacy and safety of mechanical thrombectomy in patients with cerebral venous thrombosis, by performing a systematic review of the literature. We identified studies published between January 1995 and February 2014 from PubMed and Ovid. We included all cases of cerebral venous thrombosis in whom mechanical thrombectomy was performed with or without intrasinus thrombolysis. Good outcome was defined as normal or mild neurological deficits at discharge (modified Rankin Scale, 0-2). Secondary outcome variables included periprocedural complications and recanalization rates. Our study included 42 studies (185 patients). Sixty percent of patient had a pretreatment intracerebral hemorrhage and 47% were stuporous or comatose. AngioJet was the most commonly used device (40%). Intrasinus thrombolysis was used in 131 patients (71%). Overall, 156 (84%) patients had a good outcome and 22 (12%) died. Nine (5%) patients had no recanalization, 38 (21%) had partial, and 137 (74%) had near to complete recanalization. The major periprocedural complication was new or increased intracerebral hemorrhage (10%). The use of AngioJet was associated with lower rate of complete recanalization (odds ratio, 0.2; 95% confidence interval, 0.09-0.4) and lower chance of good outcome (odds ratio, 0.5; 95% confidence interval, 0.2-1.0). Our systematic review suggests that mechanical thrombectomy is reasonably safe but controlled studies are required to provide a definitive answer on its efficacy and safety in patients with cerebral venous thrombosis.

Targeted Deletion of Selenium Transport and Recycling Pathways in Mice: Neurological and Metabolic Consequences

Selenoproteins function in essential biological functions, are particularly known for their key roles in antioxidant defense, and are synthesized via a unique translational mechanism involving recoding of UGA codons to specify selenocysteine instead of stop. Selenoprotein P (Sepp1) contains multiple selenocysteine residues and is thought to act in selenium transport. Selenocysteine lyase (Scly) decomposes selenocysteine to alanine and selenide, the latter of which is utilized for new selenoprotein biosynthesis. Genetic deletion of Sepp1 combined with feeding a selenium‐deficient diet results in severe neurological dysfunction and brainstem neurodegeneration. We hypothesized that mice lacking Scly might exhibit similar deficits. Surprisingly, Scly KO mice raised on a Se‐adequate diet exhibit hyperinsulinemia, hyperleptinemia, glucose intolerance, and hepatic steatosis. Upon dietary Se restriction, Scly KO animals develop several characteristics of metabolic syndrome, such as obesity, fatty liver, and hypercholesterolemia, with aggravated hyperleptinemia, hyperinsulinemia, and glucose intolerance. In addition, they exhibit mild neurological deficits. We created novel transgenic mice constitutively lacking both genes and characterized the phenotype. Deletion of Sepp1 and Scly further aggravates the phenotypes of either single knockout mouse, as these mice needed supraphysiological selenium supplementation to survive, and surviving mice exhibited impaired motor coordination, audiogenic seizures, and brainstem neurodegeneration. These findings provide the first in vivo evidence that Scly and Sepp1 work cooperatively to maintain selenoprotein function in the mammalian brain.

Time course of changes in the development of gait disorders in multiple sclerosis

Objective : to estimate the time course of changes in foot biomechanical function as multiple sclerosis (MS) progresses in patients with different degrees of disability compared to a control group. Patients and methods. To estimate the time course of changes in gait disorders in MS, changes in foot biomechanical function were explored in 30 patients with relapsing-remitting MS. Their neurological status was evaluated using the expanded disability status scale (EDSS); pedographic examination was made applying a plantar pressure distribution system; all the patients were examined twice. During the first examination, the patients were divided into two groups: 1) minimal neurological disorders (EDSS scores of < 3.0) and 2) moderate ones (EDSS scores of ≥3.0). Results and discussion. The patients with a mild neurological deficit showed increases in foot load and its lateralization by elevating pressure on the heads of the fourth and fifth metatarsal bones, as evidenced by a significant rise in mean pressure, maximum force, and force-time integral. These changes occurred in the absence of the patients’ complaints of changes in movements. Pedographic examination revealed the changes indicating an enlarged anterior transverse arch and the lower role of the hallux in body weight transfer in the patients with a moderate neurological deficit despite the fact that there were no further visible negative changes in a motor process or progression in neurological deficit. The pedographic examination makes it possible to estimate the degree of gait disorders caused by pyramidal and/or cerebellar lesions and to identify a leading role of this or that functional system in their genesis. Pyramidal dysfunction has impact on the pressurization of the heads of the second and third metatarsal bones. Computed pedography can identify clinically subtle movement changes and estimate the time course of changes in movement disorders in MS patients, including those to evaluate the efficiency of therapy and rehabilitation measures.