Minimal Neurological Deficit Research Articles

SCLEROSE EN PLAQUE ET GESTION DE LAPTITUDE : A PROPOS DE DEUX CAS SUIVIS AU CENTRE DEXPERTISE MEDICAL DU PERSONNEL NAVIGANT DE RABAT

Multiple sclerosis (MS) is the most common inflammatory demyelinating disease of the central nervous system, with variable manifestations, it evolves in two main forms (relapsing and remitting) with an unpredictable evolution, theprognosis may range from minimal neurological deficit to severe disability. It mainly affects the young population. Several manifestations (organic and psychological) of MS can lead to an overall decrease in flight crew performance. It includes cognitive impairment, fatigue and depression. Episodes of spasms, dysarthria, ataxia, paresthesia, diplopia and also hemiplegia can that can affect flight safety. Disease-modifying therapiescould minimize relapse rates and slow disease progression, but are not free from sometimes major side effects that can compromise flight safety. We report our experience with two cabin crew members affected by MS and fitness management. The different manifestations of MS will be discussed with an emphasis on aeromedical implications.

Technical Nuances in the Perioperative Management of Chronic Subdural Hematoma by Twin Burr Hole Craniostomy: Tips, Tricks, and Tactics

AbstractChronic subdural hematoma (CSDH) remains to be the most common neurosurgical entity usually encountered in the elderly population. With an increasing life expectancy and associated comorbidities, the incidence of CSDH is ever increasing. There is a lack of uniformity among neurosurgeons regarding management of CSDH, but surgical evacuation using twin burr hole craniostomy remains to be the most preferred modality. Other options available are twist drill craniostomy and craniotomy. A conservative approach may be preferred in a thin subdural hematoma with no or minimal neurological deficit or in high operative risk patients. Complications such as pneumocephalus, recollection, or rebleeding may be seen following surgical evacuation of CSDH. Herein we aimed to address the technical nuances associated with twin burr hole evacuation of CSDH to reduce the complications and the overall associated morbidity and mortality.

Analysis of neuropsychological and laboratory parameters in patients with cerebrovascular disease and SARS-CoV-2 compared to those without SARS-CoV-2

Background. Severe acute respiratory syndrome сoronavіrus 2 (SARS-CoV-2, formerly known as 2019-nCoV) is the cause of coronavirus disease 2019 (COVID-19), and was first reported in Wuhan, China. However, it is also contagious to humans and spreads rapidly around the world through close contact between infected people or through a relatively simple transmission mechanism (airborne transmission). COVID-19 is known to affect almost all systems of the human body. Initial reports suggest that hypertension may be a risk factor for susceptibility to SARS-CoV-2 infection, a more severe course of COVID-19, and increased mortality associated with COVID-19. It is estimated that 1–3 % of COVID-19 patients experience transient ischemic attacks with a frequency similar to other coronavirus infections (SARS-CoV-1 and MERS-CoV). The cause of ischemic stroke associated with COVID-19 is unknown, but previous studies have suggested that an inflammatory cytokine storm may cause hypercoagulation and endothelial damage. We see that COVID-19 is closely related to neurological complications because there are potential factors that can cause them. Materials and methods. Cerebrovascular diseases were analyzed in 111 patients infected with SARS-CoV-2 (n = 71) and those without a history of SARS-CoV-2 (n = 40). The subject of the study was neuropsychological and laboratory indicators. The following methods were used: psychometric — Beck Anxiety Inventory, Hamilton Depression Rating Scale, Fatigue Assessment Scale; neuropsychological — Mini-Mental State Examination, Montreal Cognitive Assessment, Frontal Assessment Battery; clinical — neurological status; polymerase chain reaction to detect COVID-19 RNA; statistical methods. Results. In patients who suffered transient ischemic attack and ischemic stroke with a minimal neurological deficit and COVID-19, there were elevations in the erythrocyte sedimentation rate, leukocytes, segmented neutrophils, while an increase in C-reactive protein was noted in all participants with cerebrovascular disease and COVID-19, with more significant levels among those with ischemic stroke. All subgroups with COVID-19 showed an increase in D-dimer and fibrinogen with higher content in patients after ischemic stroke. Also in this subgroup, the procalcitonin index exceeded the norm, which indicates the severity of the course of COVID-19 with the addition of co-infection. Data of neuropsychological tests in patients with ischemic stroke with a minimal neurological deficit with SARS-CoV-2 revealed a decrease in the Montreal Cognitive Assessment score, indicating mild cognitive changes in these patients. The level of anxiety in patients with hypertension with frequent crises and ischemic stroke with a minimal neurological deficit was above the reference values, with a slight predominance in patients who did not have COVID-19. It follows that both laboratory and neuropsychological parameters differed in three subgroups depending on cerebrovascular disease, as well as the presence and absence of SARS-CoV-2, which makes it possible to develop more appropriate diagnostic methods in order to predict the course and outcome of COVID-19.

Intracapsular Enucleation of Brachial Plexus Schwannoma With Intraoperative Neuromonitoring: A Case Series Study and a Review of Literature.

Brachial plexus schwannoma (BPS) is a rare clinical entity that poses a significant challenge for head and neck surgeons due to its neuroanatomical complexity and potential severe complications, such as major motor or sensory neurological deficits or pain of the corresponding upper extremity. This article summarizes our experience in its diagnosis and intracapsular enucleation with intraoperative neuromonitoring (INM). A retrospective review of BPS cases treated at our tertiary medical institution was conducted between April 2020 and May 2023. The clinical and demographic data were retrieved from case notes. Totally, 3 cases were included. All 3 patients were male, aged 43 to 54 years (median age = 52). The presenting symptom was a palpable supraclavicular mass in all these cases (2 on the left side and 1 on the right side). Neuromonitoring was performed with a 4-channel nerve integrity monitor, with the electrodes placed in the upper arm and forearm muscles, as demonstrated in the literature. After exposing the mass and identifying its origin from the brachial plexus, a unipolar stimulating probe was used to stimulate the tumor surface or the nerves with a 1.0-mA current, and a longitudinal incision into the tumor capsule was made along a carefully mapped line with no INM response. Then the mass was carefully exposed and meticulously dissected from its capsule to achieve an intact enucleation. Immediate postoperative neurological deficit was documented in Case 1 as a mild grasping weakness. The recovery of the other 2 patients was uneventful. The follow-up duration was 7 to 38 months (median = 8 months). The minor motor deficit of Case 1 recovered completely 1 month after surgery. No recurrence of BPS was observed. Intracapsular enucleation with INM could result in complete removal of BPS and minimal postoperative neurological deficit, whose recovery was quick and satisfactory.

The Use of Physical Rehabilitation to Improve Outcome Following Traumatic Brain Injury in Dog- A Case Report

Traumatic brain injury (TBI) in the canine patient is a common sequela to head trauma accidents such as vehicular trauma or high-rise falls. A 3-year-old, intact female mixed breed dog presented to Purdue University College of Veterinary Medicine following a suspected hawk attack. At presentation, this non-ambulatory, tetraparetic, mentally inappropriate, and stuporous patient was diagnosed with suspected TBI secondary to trauma. Physical rehabilitation was initiated and continued during the hospitalization period and afterwards on an outpatient basis. Rehabilitation focused on a combination of mental stimulation, proprioceptive and balance work, and sensory stimulation. Therapies and exercises used consisted of massage, stretching, passive range of motion (PROM), assisted standing, weight shifting, underwater treadmill (UWTM), and the use of textured surfaces, music, and positive encouragement. The patient’s coordination, balance, and mentation greatly improved. At a follow-up visit 4 months post-injury, she could ambulate with no assistance and had minimal neurological deficits. Physical rehabilitation after TBI in humans is considered to be standard of care. In this veterinary patient, rehabilitation contributed to healing, return of function, and good quality of life.

Surgical resection of glioblastoma in basal ganglia and utility of exoscope: Technical case reports.

Due to the presence of many perforating arteries and the deep location of basal ganglia tumors, dissection of the perforating arteries is critical during tumor resection. However, this is challenging as these arteries are deeply embedded in the cerebrum. Surgeons need to bend their heads for a long time using operative microscope and it is uncomfortable for the operating surgeon. A high-definition (4K-HD) 3D exoscope system can significantly improve the surgeon's posture during resection and widen the operating view field considerably by adjusting the camera angle. We report two cases of glioblastoma (GBM) involving basal ganglia. We used a 4K-HD 3D exoscope system for resecting the tumor and analyzed the intraoperative visualization of the operative fields. We could approach the deeply located feeding arteries before successfully resecting the tumor using a 4K-HD 3D exoscope system which would have been difficult with the sole use of an operative microscope. The postoperative recoveries were uneventful in both cases. However, postoperative magnetic resonance imaging showed infarction around the caudate head and corona radiata in one of the cases. This study has highlighted using a 4K-HD 3D exoscope system in dissecting GBM involving basal ganglia. Although postoperative infarction is a risk, we could successfully visualize and dissect the tumors with minimal neurological deficits.

Successful combination treatment of bilateral guttural pouch mycosis with salpingopharyngeal fistulation and potassium iodide

SummaryA 9‐month‐old Thoroughbred colt was presented to the University College Dublin Veterinary Hospital for investigation of suspected neck pain. Clinical signs included severe dullness, bilateral mucopurulent nasal discharge, ptosis of the right eyelid, reduced range of motion of the neck and ataxia. Endoscopy of the medial compartment of both guttural pouches showed fungal‐like plaques, from which Aspergillus was cultured. Laser salpingopharyngeal fistulation was performed under standing sedation and the colt received treatment with oral potassium iodide. The colt developed bacteraemia post‐operatively which resolved after antimicrobial treatment. Serial endoscopic evaluation of the guttural pouches showed complete resolution of fungal plaques 4 months post‐operatively. Minimal neurologic deficits remained 6 months post‐operatively. This report highlights the importance of considering guttural pouch mycosis in young horses and those presenting with reduced range of neck motion and neck pain. It offers support for the use of salpingopharyngostomy as an effective treatment method for guttural pouch mycosis and documents its use in the case of bilateral disease confirmed by fungal culture. It also documents the recovery of a horse from GPM with associated severe neurological signs.

Anterior Inter-hemispheric Transcallosal Approach for Resection of Colloid Cyst: A Video Abstract

Abstract Background Although histologically benign, colloid cysts have been an entity of interest to neurosurgeons due to the wide array of possible presentations ranging from asymptomatic to high ICP symptoms to sudden death. It is estimated that colloid cysts represent 0.3 to 2% of all brain tumors.1 As they are typically located in the third ventricle, multiple approaches have been adapted and developed for the maximum resection with the least complications given the sensitive anatomy in the area.1 2 The interhemispheric transcallosal approach can be safely performed to fully resect a third ventricle colloid cyst with close to zero recurrence rate and minimal to none permanent deficits.3 This video is an educational illustration of the surgical technique and the related anatomy for the interhemispheric transcallosal approach and how to provide best chances of a benign postoperative course. Case Description In this surgical video, we present a case of a 20-year-old male, a known case of hypertension and un-controlled diabetes type-1, presented to our hospital with on and off headache, dizziness, and diplopia that gradually progressed. His neurological exam was unremarkable including memory function. CT and MRI scans demonstrated a rounded sharply demarcated lesion at the at the roof of the third ventricle, measuring 1 × 1 cm in size. The patient underwent an anterior inter-hemispheric transcallosal approach, with gross total resection of the cyst. In the follow-up office visit, the patient headache has resolved, and he had no seizures with preserved memory functions. Conclusion When removal of the colloid cyst is indicated, the interhemispheric transcallosal approach can be performed safely with gross total resection and minimal neurological deficit. This is a surgical demonstration of the transcallosal approach showcasing the surgical corridors and related anatomy.

Abstract Number ‐ 72: A Successful Emergent Endovascular Mechanical Thrombectomy in An Extensive Deep Cerebral Venous Sinus Thrombosis

Introduction Cerebral venous sinus thrombosis (CVST) is an uncommon variant of strokes, accounting for 0.5‐1% of all cases. Current guidelines recommend systemic anticoagulation as the first line therapy with endovascular approach reserved for those who fail to recanalize. We describe a 24‐year old female who presented with 3 days of headache and right sided weakness and was found to have extensive deep CVST with intracerebral hemorrhage and obstructive hydrocephalus. She underwent successful emergent intravenous thrombectomy with complete recanalization after clinical and radiological deterioration despite optimal systemic anticoagulation and bilateral external ventricular drains (EVDs). Methods The patient underwent thrombectomy under general anesthesia. Angiogram through the right radial artery was performed showing extensive thrombosis involving straight sinus, inferior sagittal sinus, vein of Galen and the internal cerebral vein. A right common femoral vein access was obtained and 80 cm Cook shuttle was placed and advanced to left internal jugular vein. Two passes mechanical thrombectomy using Y stent technique with the solitaire 6×40mm and Embotrap 6.5×45 mm stent retrievers and Zoom 008 with 071 aspiration catheters was performed with minimal recanalization of straight and inferior sinus. Attempted active aspiration and Power Pulse lytic thrombectomy through AngioJet Ultra Solent Omni Set 120cm but it was not long enough which was switched with 135cm length with successful access. This was followed by repeated attempts of aspirations with zoom 088 and 071 aspiration catheters resulting in near complete recanalization of straight, inferior sagittal sinuses, internal cerebral vein and vein of Galen. Results Two pass Simultaneous Mechanical Y‐Stent Retriever Thrombectomy andContact Aspiration Thrombectomy was performed with minimalrecanalization and reperfusion of straight sinus and inferiorsagittal sinus. This was followed by three pass Contact Aspiration Thrombectomy with large aspiration catheters and AngioJet Sets with near complete recanalization and drainage of straight sinus, inferior sagittal sinus, internal cerebral vein and vein of Galen. After 7 days of close ICU monitoring for malignant intracranial hypertension, patient was ultimately weaned off sedation and bilateral EVDs, extubated and transitioned to oral anticoagulation with significant clinical improvement and minimal residual neurological deficits. Conclusions Limited data is available on mechanical thrombectomies in deep CVST with hemorrhagic transformation. Our study describes a favorable outcome with combined stent retriever and aspiration thrombectomy approach. AngioJet 135cm Aspiration Catheter with Power Pulse lytic are also possible option to treat tough venous intracranial clots. Additional randomized controlled trials are needed to establish superiority between various approaches of mechanical venous thrombectomy in patients who have deep venous sinus thrombosis that fail medical management.

Identification of novel compound heterozygous LRBA mutations associated with recurrent hemophagocytic lymphohistiocytosis and CNS manifestations

Background: Lipopolysaccharide-responsive beige-like anchor (LRBA) is an intracellular protein that regulates the recycling of cytotoxic T lymphocyte-associated protein 4 (CTLA4), an immune checkpoint molecule which prevents ongoing activation of T cells. Deficiency of LRBA results in increased trafficking and degradation of CTLA4, and consequently, uncontrolled T cell responses. The phenotypic spectrum of LRBA deficiency arising from biallelic loss-of-function typically includes recurrent infections, autoimmunity, lymphoproliferation, chronic diarrhea, hypogammaglobulinemia, and cytopenia. Aim: To report an atypical presentation of LRBA deficiency arising from a set of compound heterozygous LRBA variants, encompassing recurrent hemophagocytic lymphocytosis (HLH) and neurological manifestations. Methods: Clinical data was gathered through retrospective chart review. Expanded genetic analysis including whole exome sequencing was performed. Results: Our patient initially presented at age 15 months with fever, seizures, and encephalopathy. HLH-work-up showed bicytopenia, elevated ferritin and triglyceride, and low fibrinogen, however, he did not yet meet the diagnostic criteria for HLH. MRI brain and EEG at diagnosis was suggestive of acute necrotizing encephalopathy of childhood. He responded to pulsed IV methylprednisolone treatment with minimal residual neurological deficit on follow-up. At 36 months of age, he had a repeat presentation and rapidly deteriorated. He developed severe encephalopathy with fixed dilated pupils. Whole exome sequencing revealed a set of compound heterozygous missense variants in the LRBA gene, a novel c.2206A>T (p.R736W) and c.5989C>T (p.R1997C) variant. Conclusion: Compound heterozygous mutations in the LRBA gene caused an atypical presentation of recurrent HLH with central nervous system (CNS) manifestations in our patient. Statement of Novelty: We herein report a novel set of compound heterozygous mutations in LRBA with atypical presentation of recurrent HLH with CNS manifestations, thus expanding the known phenotypic spectrum of LRBA deficiency.

Intra-Operative Supplementary Motor Area Aphosia During Awake Craniotomy a Case Report

Introduction: Language function is complex, involving association between Broca’s motor speech area, Wernicke’s sensory speech area and various interconnected cortical and sub-cortical regions. For lesions in eloquent areas, awake craniotomy with intra-operative neurological monitoring of motor and language function, aids in maximal safe resection of lesion with minimal neurological deficit. Case presentation: We present a case of 40-year-old patient with left frontal lobe lesion involving motor and speech area who underwent awake craniotomy under scalp block and titrated sedation. Though resection was in safe zone as marked both by neuro-navigation and direct electrical stimulation, patient developed aphasia intra-operatively. The aphasia resolved post-operatively with speech therapy over two weeks. Resection in Supplementary motor area (SMA) in the dominant hemisphere may be the likely cause of aphasia in this patient, resulting in reversible SMA syndrome. Conclusion: SMA syndrome must be considered as differential diagnosis of deficit during awake craniotomy when resection is in SMA. Keywords: Aphasia, Supplementary motor area, Awake craniotomy, Eloquent areas

Review of the Elemental Status in Blood Serum in Patients with Ischemic Stroke

The study of the elemental status in the modern paradigm of medical diagnostics occupies an increasingly large niche due to the possible use of trace elements as possible predictors of cerebrovascular pathologies. Moreover, the great importance of the elemental component in the main enzymatic systems of metabolism allows us to consider them also as a therapeutic target. There are many mechanisms in the pathophysiology of stroke development, each of which, in one way or another, is mediated through the interaction of regulatory proteins with trace elements as cofactors. Therefore, it is necessary to pay close attention to elemental homeostasis in the focus of ischemic pathologies. Aim. Systematization of the known pathogenetic effects of the most metabolic homeostasis important elements on the course of stroke, both contributing factors to earlier rehabilitation and minimal neurological deficit after the ischemic event itself, and factors aggravating the recovery process and leading to serious neurological consequences. This pursues not only a prognostic goal to determine the severity of ischemia or to identify risk groups with certain shifts in elemental constants, but also the therapeutic one — to replace the falling functions of the dropping metabolic agents, as happens with the elements involved in antioxidant systems. It is also necessary to develop a methodology for stopping the excess of nerve cells mediating excitotoxicity with calcium ions, which closes the vicious circle of vascular necrosis with additional destruction of the nervous tissue. Conclusion. The conclusions that we can summarize quite convincingly indicate a significant contribution of the elemental status to the pathogenesis of ischemic stroke. Dysregulation of the elemental component can force the damaging effect of ischemia on brain cells. At the same time, many elements show a surplus during an ischemic event: Li, I, Mn, Zn, As, Se, Pb, Sr, Ni, however, not all of the presented elements negatively affect the course of stroke, since an increase in the level of some metals may be compensatory in nature, and for their further applicability as diagnostic and therapeutic agents, similar analytics are required.

Prehabilitation and rehabilitation using data-driven, parcel-guided transcranial magnetic stimulation treatment for brain tumor surgery

Improved knowledge of the neuroplastic potential of the brain connectome has facilitated the advancement of neuromodulatory treatments for brain tumor patients especially in the perioperative period. More recently, the idea of inducing neuroplastic changes before surgery as “prehabilitation” has been suggested in low-grade gliomas with favorable data. However, it is uncertain the degree to which this treatment with transcranial magnetic stimulation (TMS) would benefit patients with high-grade gliomas, especially with additional rehabilitation after surgery and targets defined by personalized connectomic data. The current report details a case of a patient with recurrent glioblastoma in the right motor area 2 years after previous total resection. Given the desire for a more aggressive recurrent surgery in a highly functional area, the authors decided to proceed with “prehabilitation” by stimulating the surrounding motor cortices around the lesion to turn down the motor cortex connectivity before the recurrent surgery and then completing “rehabilitation” after the surgery. Structural-functional connectomic analyses were completed using Infinitome software based on an individualized patient brain atlas using machine-learning based parcellations. Repetitive TMS was employed, specifically using continuous and intermittent theta burst stimulation protocols. Prehabilitation consisted of using continuous theta burst stimulation at the estimated surgical entry point parcel and intermittent theta burst stimulation at adjacent parcellations for a total of 10 days with 5 sessions per day per target leading up until the surgery. A gross-total resection was obtained, but the patient woke up with left-sided hemiparesis. Resting-state functional magnetic resonance imaging derived connectivity demonstrated a case of a primarily pure cingulate-motor resection causing hemiplegia with an intact corticospinal tract and supplementary motor area. Functional connectivity outliers in cingulate-motor parcels were identified and compared with connectivity matrices from a healthy control atlas. Anomalies, parcels defined as functioning significantly outside a normal range, were chosen as rehabilitation TMS targets to be similarly treated for a total of 10 days with 5 sessions per day per target approximately two weeks after surgery. By using continuous theta burst stimulation on hyperconnected parcels and intermittent theta burst stimulation on hypoconnected parcels, the patient demonstrated significant motor improvement with only 4+/5 strength in the left arm 1 month after surgery. This report demonstrates for the first time the feasibility of using TMS treatment for glioblastoma surgery near “eloquent” cortices as a means of prehabilitation before surgery and rehabilitation after surgery. This parcel-guided approach for TMS treatment based on the cortical site of entry and individualized connectivity analyses allowed for maximal tumor resection and minimal long-term neurologic deficits.

The importance of assessing general motor activity in premature infants for predicting neurological outcomes

Conventional methods of neurological assessment of infants can detect nervous system damage, but also have a weakness, i.e., the inability to make predictions for neurological deficits. Prechtl's general movement assessment is a diagnostic tool for the functional assessment of young nervous system. The aim of the study was to assess the quality of spontaneous motor activity in preterm newborns as well as to determine the neurological outcome at the age of 24 months. After that, the predictive value of spontaneous motor activity for neuro-developmental outcome at the age of 24 months was determined. The study included 160 pre-terms children, and designed as a prospective clinical study. Observation of spontaneous motor activity was performed according to the principles of Prechtl's method. Spontaneous motor activity was observed in three periods for each newborn: within 5 days of birth, in the period of 44-46 gestation weeks, and in the period of 50-54 gestation weeks of post-menstrual age. Neurological outcome was assessed at the age of 24 months, and was classified as: normal finding, minimal neurological dysfunction, and cerebral palsy. All preterms, who presented normal patterns of spontaneous movements in neonatal and infant periods had a normal neurological functional outcomes at the age of 24 months. Newborns with pathological patterns of movement (cramped synchronized and absence of fidgety movements) in neonate and infant periods in the final outcomes had minimal neurological dysfunction or cerebral palsy. Assessment of general movement in preterms is a valuable method in prediction of dysfunctions in later neurological development. Early detection of symptoms of minimal neurological deficit and cerebral palsy is of crucial importance since it enables timely inclusion of children into neuro-developmental treatment.

Idiopathic brachial plexopathy after pacemaker implant.

A middle-aged woman presented with symptomatic complete heart block and underwent an uneventful dual chamber pacemaker implantation. Three weeks post procedure, she developed left arm pain and weakness, with neurological localization to the lower trunk of left brachial plexus. Possibilities of traumatic compression by the device/leads or postoperative idiopathic brachial plexopathy were considered. After ruling out traumatic causes, she was started on oral steroids, to which she responded remarkably. This case highlights the importance of recognizing this rare cause of brachial plexopathy following pacemaker implantation, because not only does an expedited diagnosis and medical treatment lead to prompt recovery with minimal neurological deficits, but it also circumvents an unnecessary surgical re-exploration.

Emerging Super-specialty of Neurology: Intraoperative Neurophysiological Monitoring (IONM) and Experience in Various Neurosurgeries at a Tertiary Care Hospital in Doha, Qatar.

IntroductionIntraoperative neurophysiological monitoring (IONM) helps in better patient outcomes by minimizing risks related to the functional status of the nervous system during surgical procedures. An IONM alert to the surgical team during the surgery can help them identify the cause and take immediate corrective action. IONM confers possible benefits, including improved surgical morbidity and mortality, better patient care, minimal neurological deficits, reduced hospital stay, medical costs, and litigation risk. In addition, a highly skilled IONM team will make a better patient outcome.MethodsWe retrospectively reviewed 62 consecutive patients who underwent intracranial and spinal neurosurgical procedures. Multimodality IONM was utilized, including somatosensory evoked potentials, transcranial electrical motor evoked potential, spontaneous and triggered electromyography, electroencephalography, electrocorticography, cortical sensory mapping, and direct electrical cortical stimulation. Of a total of 62 patients, two patients revealed neurotonic EMG discharges during IONM, and most patients woke up without any new neurological deficit.ResultsSixty-two patients were included, ranging from age 5 to 77 years (mean 43.5 years), with 54.8% men and 45.2% female. Multimodality IONM was used in all patients. Two EMG alerts were recorded during IONM, during a brain tumor resection, and right acetabular hip surgery with postoperative right foot drop.ConclusionMultimodality IONM is the gold standard of care for any surgical services and is used as real-time monitoring of functional integrity of neural structures at risk. If utilized by trained and expert teams, numerous surgeries may benefit from multimodality intraoperative neurophysiologic monitoring.

Порівняльна ефективність гормональної пульс-терапії при рецидивуючому та вторинно-прогредієнтному типах перебігу розсіяного склерозу з різним характером прогнозу. Повідомлення I. Ефективність гормональної пульс-терапії в дебюті та на рецидивуючому етапі п

Проведено дослідження ефективності пульс-терапії глюкокортикоїдами (ГКT) в дебюті та на рецидивуючому етапі (РЕ) у 98 хворих з розсіяним склерозом (РС): 28 осіб (24 жінки і 4 чоловіки) з невизначеним прогнозом при рецидивуючому перебігу (РП) — 1-ша група; 30 осіб (21 жінка і 9 чоловіків) з невизначеним прогнозом при вторинно-прогредієнтному перебігу (ВПП) — 2-га група; 40 осіб (36 жінок і 4 чоловіки) з несприятливим прогнозом при ВПП — 3-тя група. Проводився облік наступних клінічних показників: вік, тривалість захворювання, вік дебюту, тяжкість дебютів, тривалість ремісії після дебюту, тривалість рецидивуючого етапу, тяжкість і число рецидивів на РЕ, середня частота рецидивів і тривалість ремісій на РЕ, ступінь інвалідизації за шкалою EDSS. Проведено 287 курсів ГКТ-терапії: при невизначеному прогнозі РП — 98 (у дебютах — 9, на РЕ — 89); при невизначеному прогнозі ВПП — 99 (у дебютах — 3, на РЕ — 96); при несприятливому прогнозі ВПП — 90 (у дебютах — 8, на РЕ — 82). Клініко-діагностичні критерії ефективності лікування в усіх групах хворих включали динаміку регресу неврологічної симптоматики під впливом першого курсу ГКТ-терапії на етапі дебютів; порівняльну оцінку тривалості ремісії після дебюту при прийомі і без прийому ГКТ; середню частоту рецидивів на РЕ під впливом повторних курсів ГКТ-терапії; тривалість ремісій після 1-го курсу гормональної терапії; тривалість РЕ залежно від тривалості ремісій після першого курсу ГКТ-терапії. У групі хворих з невизначеним прогнозом РП додатково враховувалися: тривалість ремісій перед останнім курсом ГКТ; швидкість прогресування на РЕ; динаміка балів за шкалою інвалідизації EDSS після 1-го і перед останнім курсами ГКТ-терапії. Проведене дослідження показало, що в процесі лікування клінічні показники, що характеризують перебіг дебютів і РЕ, зазнають складної системної реорганізації залежно від типу перебігу та характеру прогнозу. Найбільш ефективною гормональна терапія виявилася при невизначеному прогнозі РП. Для цієї групи хворих було виділено дві категорії ефективності лікування: висока (у 17 осіб) і помірна (в 11 осіб). Критерієм ефективності лікування служила позитивна динаміка більшості клінічних показників. Вона проявлялася швидким і повноцінним регресом неврологічної симптоматики в дебютах, збільшенням тривалості ремісії після дебюту, зменшенням частоти і тяжкості рецидивів на РЕ, збільшенням числа хворих з величиною середньої частоти рецидивів < 1,0, збереженням мінімального неврологічного дефіциту, низькою швидкістю прогресування, нерізкою негативною динамікою балів за шкалою інвалідизації EDSS. У результаті зазначеної реорганізації збільшувалась тривалість РЕ і відбувалося запобігання безпосередньої загрози трансформації РП у ВПП.

Advantages and limitations of the use of tractography and fMRI in the treatment of anaplastic glioma

The possibility of using only tractography as a preoperative diagnosis of anaplastic glioma is limited due to its inability to show the exact functional location of the tumor; therefore, the combination of tractography and fMRI seems to be a more promising complex diagnostic method. In neurooncology, complete resection without or with minimal neurological deficit is the goal of surgical intervention. The aim of the study was to investigate the advantages and limitations of the use of tractography and fMRI in the treatment of anaplastic glioma compared to standard CT or MRI. The study involved 48 patients who were divided into two groups based on the use of fMRI and tractography: group A (24 patients) and without it — group B (24 patients). The groups were compared in terms of age, sex, histological subtype of anaplastic glioma, degree of resection, postoperative complications, and dynamics of neurological disorders. The combination of fMRI and tractography is the best preoperative diagnosis, it is safe and allows localizing neural pathways, preserve them during surgery, and reduce postoperative neurological deficits.

Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid).

Objective: Endovascular embolization using non-adhesive agents (e.g., ethylene vinyl alcohol copolymer with suspended micronized tantalum dissolved in dimethyl sulfoxide; Squid, Balt Extrusion) is an established treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and hypervascular neoplasms. Middle meningeal artery (MMA) embolization is a relatively new concept for treating chronic subdural hematomas (CSDH). This study aimed to evaluate the safety and effectiveness of the use of Squid in the endovascular treatment of CSDH. Methods: Embolization was offered to patients with CSDH with minimal or moderate neurological deficits and patients who had previously undergone open surgery to evacuate their CSDH without a significant effect. Distal catheterization of the MMA was followed by embolization of the hematoma capsule with Squid 12 or Squid 18. Safety endpoints were ischemic or hemorrhagic stroke and any other adverse event of the endovascular procedure. Efficacy endpoints were the feasibility of the intended procedure and a ≥ 50% reduction of the maximum depth of the CSDH confirmed by follow-up computed tomography (CT) after >3 months. Results: Between November 2019 and July 2021, 10 patients (3 female and 7 male, age range 42–89 years) were enrolled. Five patients had bilateral hematomas, and five patients had previously been operated on with no significant effect and recurrent hematoma formation. The attempted embolization was technically possible in all patients. No technical or clinical complication was encountered. During a post-procedural follow-up (median 90 days), 10 patients improved clinically. A complete resolution of the CSDH was observed in 10 patients. The clinical condition of all enrolled patients during the so-far last contact was rated mRS 0 or 1. Conclusion: A distal catheterization of the MMA for the endovascular embolization of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered.

Cognitive function is an important determinant of employment amongst young ischaemic stroke survivors with good physical recovery.

This cross-sectional cohort study aims at investigating young ischaemic stroke survivors with good physical recovery 7years post-stroke in order to analyze the relation between late cognitive ability and employment. Consecutive ischaemic stroke survivors participating in the Sahlgrenska Academy Study on Ischemic Stroke, <55years of age at stroke onset, and with no or minimal persisting neurological deficits corresponding to a score ≤2 on the National Institutes of Health Stroke Scale at long-term follow-up 7years post-stroke were included. At this follow-up, the participants were assessed with respect to general cognitive function, processing speed, executive functions, cardiovascular risk factors, self-reported employment, cognitive difficulties, fatigue, depressive symptoms, anxiety and physical function. Seven years post-stroke 112/142 (79%) had part-time or full-time work and 30/142 (21%) had full-time disability pension or sick leave. Compared to those with full-time disability pension or sick leave, participants with current employment demonstrated significantly better performance with respect to general cognitive function and processing speed, and significantly lower self-ratings for cognitive difficulties, physical limitations, fatigue and depressed mood. Multivariable logistic regression selected self-rated memory (odds ratio [OR] 2.61, 95% confidence interval [CI] 1.61-4.21), processing speed (OR 3.50, 95% CI 1.67-7.33) and self-rated communication skills (OR 3.46, 95% CI 1.75-6.85) as most important correlates (area under the curve 0.83-0.87) of having current employment. This study indicates that cognitive dysfunction is an important contributor to long-term work disability amongst young stroke survivors with good physical recovery.