Minor Deficits Research Articles

Low-Threshold Monopolar Motor Mapping for Resection of Primary Motor Cortex Tumors

Microsurgery within eloquent cortex is a controversial approach because of the high risk of permanent neurological deficit. Few data exist showing the relationship between the mapping stimulation intensity required for eliciting a muscle motor evoked potential and the distance to the motor neurons; furthermore, the motor threshold at which no deficit occurs remains to be defined. To evaluate the safety of low threshold motor evoked potential mapping for tumor resection close to the primary motor cortex. Fourteen patients undergoing tumor surgery were included. Motor threshold was defined as the stimulation intensity that elicited motor evoked potentials from target muscles (amplitude > 30 μV). Monopolar high-frequency motor mapping with train-of-5 stimuli (HF-TOF; pulse duration = 500 microseconds; interstimulus interval = 4.0 milliseconds; frequency = 250 Hz) was used to determine motor response--negative sites where incision and dissection could be performed. At sites negative to 3-mA HF-TOF stimulation, the tumor was resected. HF-TOF mapping localized the motor neurons within the precentral gyrus by using variable, low-stimulation intensities. The lowest motor thresholds after final resection ranged from 3 to 6 mA, indicating close proximity of motor neurons. Postoperatively, 12 patients had no new motor deficit, 1 patient had a minor new temporary deficit (M4+, National Institutes of Health Stroke Scale 1), and another patient had a minor new permanent deficit (M4+, National Institutes of Health Stroke Scale 2). Thirteen patients had complete or gross total resection. These preliminary data demonstrate that a monopolar HF-TOF threshold > 3 mA was not associated with a significant new motor deficit.

Decompressive Hemicraniectomy and Duroplasty in Toddlers and Preschool Children with Refractory Intracranial Hypertension after Unilateral Hemispheric Stroke

ObjectiveLife-threatening hemispheric stroke is associated with a high mortality and morbidity. Decompressive hemicraniectomy has been regarded as an effective treatment option for refractory intracranial hypertension. Here, we reported the clinical course of 5 children with decompressive craniectomy and duroplasty after non-traumatic refractory intracranial hypertension.MethodsFour toddlers and one preschool-girl were included in this study; there were 3 boys and 2 girls with a mean age of 34.6 months (range 17-80). Decompressive craniectomy including duroplasty was performed in cases of dilatation of pupil size after intensified standard medical therapy had proven insufficient. All children had a Pediatric Glasgow Coma Scale score <8 at pre-operation state. The mean time-point of craniectomy after stroke attack was 12 hours (range 4-19).ResultsDuring the long-term follow-up period (mean 47.6 months), no children died. One year later, when we checked their Glasgow Outcome Scale scores, only one toddler received a score of 4 (moderate disability). But the others had good recoveries although they had minor physical or mental deficits. According to the Pediatric Cerebral Performance Category Scale, 4 children received a score of 2 (mild disability).ConclusionDespite our small cases, we suggest that decompressive hemicraniectomy and duroplasty is an acceptable and life-saving treatment for refractory intracranial hypertension after unilateral hemispheric stroke in toddlers and preschool children.

Clinical outcomes of spinal epidural abscess.

ObjectiveThe aim of this study is to elucidate the clinical characteristics of patients with spinal epidural abscess (SEA) and demonstrate the risk factors, treatments and neurologic outcomes.MethodsWe retrospectively reviewed the medical records and radiologic images of 35 patients admitted to our department with SEA between March 1987 and April 2011. While we performed decompressive laminectomy and abscess drainage on 19 patients (54.3%), and 16 patients (45.7%) initially received conservative therapy with antibiotics alone. Medical Research Council (MRC) scale was applied to estimate results objectively.ResultsThe neurological outcome data showed improved MRC scale from 14 (40%) patients. 13 (37.1%) patients showed unchanged MRC scale and 8 (22.9%) patients revealed worsened MRC scale at the time of discharge. The patients with surgical treatment showed more improved MRC scale than the patients with conservative treatment and this was statistically significant (p=0.001) on univariate analysis. Initially, patients with decreased MRC scale and rapidly progressing neurological deficit underwent emergency surgery within 24 hours. Patients with intact MRC scale and minor neurological deficit received delayed surgery or conservative management with antibiotics. Among 19 patients those who experienced emergent operations within 24 hours showed better prognosis than those who underwent delayed operations after 24 hours.ConclusionSurgical treatment is the modality of choice in patients with SEA and urgent surgery especially is indicated in patients with neurological deficits. And early surgery is more effective in neurological improvements than delayed surgery and conservative management.

Hanging-induced burst suppression pattern in EEG

Lethal suspension (hanging) is one of the most common methods of attempting suicide. Spinal fractures, cognitive and motor deficits as well as epileptic seizures can be detected after unsuccessful hanging attempts. Introduced here is the case of a 25-year-old man exemplifying the clinical observations stated hereafter, who was conveyed to our emergency room after having survived attempted suicide by hanging, with his post-anoxic burst-suppression electroencephalography (BS-EEG) pattern and clinical diagnoses in the post-comatose stage. The patient's state of consciousness was gradually improved over a period of time. His neuropsychiatric assessment proved that memory deficit, a slight lack of attention and minor executive dysfunction was observed a month after the patient was discharged. Although the BS-EEG pattern indicates severe brain dysfunction, it is a poor prognostic factor; rarely, patients survive with minor cognitive deficits and can perform their normal daily activities.

Embryo death in cattle: an update

For heifers, beef and moderate-yielding dairy cows, fertilisation generally exceeds 90%. In high-producing dairy cows, it may be lower and possibly more variable. The major component of embryo loss occurs before Day 16 following breeding, with emerging evidence of greater losses before Day 8 in high-producing dairy cows. Late embryo loss causes serious economic losses because it is often recognised too late to rebreed females. Systemic concentrations of progesterone during the cycles both preceding and following insemination affect embryo survival; too-high or too-low a concentration has been shown to be negatively associated with survival rate. Energy balance and dry matter intake during the 4 weeks after calving are critically important in determining conception rate when cows are inseminated 70 to 100 days after calving. More balanced breeding strategies with greater emphasis on fertility, feed intake and energy must be developed. Genetic variability for fertility traits can be exploited; genomic technology will not only provide scientists with an improved understanding of the underlying biological processes involved in fertilisation and the establishment of pregnancy, but could identify genes responsible for improved embryo survival. Their incorporation into breeding objectives would increase the rate of genetic progress for embryo survival. There is a range of easily adoptable management factors, under producer control, that can either directly increase embryo survival or ameliorate the consequences of low embryo survival rates. The correction of minor deficits in several areas can have a substantial overall effect on herd reproductive performance.

A preliminary study on free medial sural artery perforator flap for head and neck reconstruction following tumor ablation

To investigate the application of free medial sural artery perforator flap to reconstruct the defect following head and neck tumor ablation. From April 2010 to January 2011, the defects after head and neck tumor resection were reconstructed with free medial sural artery perforator flaps in 16 patients. The clinical data were collected and analyzed, including site and histology of tumor, the skin paddle's size of the flap, the length of pedicle, the number of major perforators and donor-site morbidity. Medial gastrocnemius territories were evaluated before operation and free medial sural artery perforator flaps were used to reconstruct the defect after tumor ablation in 16 cases. One flap partially survived due to venous thrombosis. All of the other 15 flaps succeeded. The donor site was primarily closed in 15 cases and skin graft was applied in one case. All donor sites except one case healed in first intention. Long-term follow-up showed satisfying receipt-site reconstruction results with good functional and cosmetic outcome in the donor site. There was only minor sensory deficit in the donor site. The medial sural artery perforator flap is reliable for reconstruction of the small to medium-sized defect in head and neck region with less donor site morbidity.

Begutachtung zerebraler Ischämien und Blutungen

Cerebral ischemia and hemorrhage are the most frequent cause of invalidity and disability in the elderly, corresponding to the significance of these diseases for social law and expert opinion. The sequelae of media infarcts and extended hemorrhage are obvious and offer little reason for litigation. Conflicts occur in cases of minor deficits and less obvious neuropsychological or psychiatric symptoms, including mental, cognitive, mnestic and executive functions.

Focal brain atrophy in gastric bypass patients with cognitive complaints

Recently, we have identified a series of patients presenting with cognitive complaints after gastric bypass, without any identifiable etiology. We aimed to determine if focal brain atrophy could account for the complaints. A retrospective case series was performed to identify patients with cognitive complaints following gastric bypass who had a volumetric MRI. Voxel-based morphometry was used to assess patterns of grey matter loss in all 10 patients identified, compared to 10 age and gender-matched controls. All patients had undergone Roux-en-Y gastric bypass surgery at a median age of 54 (range: 46–64). Cognitive complaints developed at a median age of 57 (52–69). Formal neuropsychometric testing revealed only minor deficits. No nutritional abnormalities were identified. Voxel-based morphometry demonstrated focal thalamic atrophy in the gastric bypass patients when compared to controls. Patients with cognitive complaints after gastric bypass surgery may have focal thalamic brain atrophy that could result in cognitive impairment.

Effect of neonatal resuscitation courses on long‐term neurodevelopmental outcomes of newborn infants with perinatal asphyxia

In previous studies, it has been demonstrated that Neonatal Resuscitation Program (NRP) courses improve the early outcomes of infants with perinatal asphyxia, but there has been no evidence to demonstrate the effect of NRP on long-term outcomes of perinatal asphyxia. The goal of the present study was to determine the effect of NRP courses on the long-term neurodevelopmental outcome of perinatal asphyxia. This prospective study included infants referred to the Neonatal Unit during the years 2003-2005. Those patients who were referred before NRP courses (pretraining period) were designated as group 1, those who were referred after the first NRP course (transition period) as group 2, and those who were referred after the second NRP course (post-training period) as group 3. Neurodevelopmental outcomes were assessed and compared at 4-6 years of age. The study involved 40 patients: 23 in group 1, nine in group 2 and eight in group 3. The number of patients who had been diagnosed with cerebral palsy was 13 in group 1, two in group 2, and one in group 3, which was a significant decrease. The number of patients with seizures and electroencephalography abnormality was 12 and 14 in group 1, three and two in group 2, and one and one in group 3, respectively, which was also a significant decrease. NRP courses have positive effects on short-term as well as long-term neurodevelopmental outcomes of infants with perinatal asphyxia. Further studies are required to determine the effects of NRP courses on minor deficits, such as cognitive and behavioral disturbances.

Accidental Chopstick Injury Resulting in Internal Capsule Lesion and Intracerebral Hemorrhage

A 3-yr-old boy was evaluated at a physical medicine and rehabilitation outpatient clinic, having presented with left hand dystonia and a left-foot drop. There was no sensory impairment in the affected limbs. It was reported that the patient was playing with a pair of chopsticks while unattended. He apparently had fallen and a chopstick penetrated the skull through his left upper eyelid. He pulled the chopstick out on his own and then fell into a deep sleep. He woke up with clear consciousness 2 days later but showed signs of left hemiparesis. At an initial neurosurgery outpatient clinic visit, the patient's left upper eyelid penetration wound had spontaneously closed. Brain computed tomographic and magnetic resonance images revealed a penetrating tract from the left upper eyelid to the right internal capsule, causing subsequent small intracerebral hemorrhage and infarction (Fig. 1A-B). There was no evidence of central nervous system infection, and no surgery was performed. After 1 mo of inpatient rehabilitation, the patient's gait pattern improved substantially with the application of a left ankle-foot orthosis.FIGURE 1: A, The fluid-attenuated inversion recovery magnetic resonance images revealing mixed hyperintensity and hypointensity bands at the right centrum semiovale, corona radiata, and posterior limb of internal capsule as well as at the rostrum and genu of the corpus callosum (arrows). B, Nonenhanced computed tomographic images showing mixed hyperdense and hypodense lesions at the right centrum semiovale, corona radiata, internal capsule, basal ganglion, and corpus callosum (arrow).Among penetrating head injuries, stabbing traumatic brain injury in childhood is rare. Children up to 4 yrs of age are prone to accidents that occur at home, where the stairways and kitchen are the most high-risk locations.1 Sharp objects tend to penetrate and enter the cranial cavity through the fragile points of the orbit, the squamous part of the temporal bone, and the paranasal sinuses.2 The occurrence of ischemic lesions and injuries to the basal ganglia and internal capsule in children is unusual. Most of these cases in children are caused by mild head trauma or varicella zoster infection and are with good outcome.3 Transient hemiparesis, arm weakness, gait disturbance, and hand dystonia are common clinical manifestations. The patient was free of seizures after this incident, and close observation was recommended without prescription of prophylactic anticonvulsants.4 This is a unique case in which our patient experienced only minor neurologic deficits from the penetrating traumatic brain injury. It reminds the physician that penetration by sharp objects must be considered in a child presenting with the previously described symptoms.

Head trauma in the cat: 2. Assessment and management of traumatic brain injury

Feline trauma patients are commonly seen in general practice and frequently have sustained some degree of brain injury. Cats with traumatic brain injuries may have a variety of clinical signs, ranging from minor neurological deficits to life-threatening neurological impairment. Appropriate management depends on prompt and accurate patient assessment, and an understanding of the pathophysiology of brain injury. The most important consideration in managing these patients is maintenance of cerebral perfusion and oxygenation. For cats with severe head injury requiring decompressive surgery, early intervention is critical. There is a limited clinical evidence base to support the treatment of traumatic brain injury in cats, despite its relative frequency in general practice. Appropriate therapy is, therefore, controversial in veterinary medicine and mostly based on experimental studies or human head trauma studies. This review, which sets out to describe the specific approach to diagnosis and management of traumatic brain injury in cats, draws on the current evidence, as far as it exists, as well as the authors' clinical experience.

Effects of DSP4 and methylphenidate on spatial memory performance in rats

In this experiment, we have investigated the spatial memory performance of rats following a central noradrenaline depletion induced by three different doses of the neurotoxin N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine (DSP4) and following administration of three different doses of methylphenidate (MPH). The rats were required to find food pellets hidden on a holeboard. The sole administration of DSP4 induced only minor cognitive deficits. However, the treatment with MPH increased the reference memory error, the impulsivity and the motor activity of the DSP4-treated rats. Since the noradrenergic terminals in a DSP4-treated rat are significantly reduced, the administration of MPH has little effect on the noradrenergic system and increases dopaminergic rather than noradrenergic activity, resulting in an imbalance with relatively high dopaminergic and low noradrenergic activities. It is suggested that a reduction of noradrenaline and an increase of dopamine induce ADHD-related deficits and that the depletion of noradrenaline is not sufficient for an appropriate rat model of ADHD.

Minor Cognitive Deficits and Mood States in HIV-1 Infected Men

The aim of this study is to evaluate cognitive deficits and the psychoemotional state of patients affected by HIV-1. The sample, composed of 30 male HIV-1 positive patients aged on average 35.59, was assessed using a psychodiagnostic protocol based on the Wechsler Adult Intelligence Scale—Revised (WAIS-R) and the Profile of Mood State (POMS) applied at the three phases of observation: baseline (T1), 6 months later (T2), and 18 months later (T3). The outcomes were compared using a non-parametric statistical technique in a multivariate context (NPC test). The results highlight significative differences in responses during the three different phases of observation (T1, T2, T3) showing, in particular, reduced cognitive performance at T3 with increased anxiety, depression, aggressiveness, asthenia, and cerebral confusion. It is thus suggested that in the study sample the condition of disease accelerates the decline of specific brain mechanisms, resulting in psychiatric disorders with reduced quality of social and working life.

Safe Resection of Arteriovenous Malformations in Eloquent Motor Areas Aided by Functional Imaging and Intraoperative Monitoring

Arteriovenous malformations (AVMs) proximal to motor cortical areas or motor projection systems are challenging to manage because of the risk of severe sensory and motor impairment. Surgical indication in these cases therefore remains controversial. To propose a standardized approach for centrally situated AVMs based on functional imaging and intraoperative electrophysiological evaluation. We conducted a retrospective analysis of 15 patients who underwent surgical treatment for AVMs in motor cortical areas or proximal to motor projections. Preoperative assessment included functional magnetic resonance and 3-dimensional tractography. Operations were performed under continuous electrophysiological monitoring aided by direct brain stimulation. We identified critical bloody supply to the motor areas by temporary occluding the feeding vessels under electrophysiological monitoring. Clinical outcome was evaluated with the modified Rankin Scale. Total resection was achieved in 12 cases, whereas electrophysiology limited total extirpation in 3 cases. A significant reduction of motor evoked potentials by up to 15% of the initial values was associated with good recovery of motor function; in contrast, the disappearance of potentials correlated with long-term impairment. The mean follow-up time was 13 months, and clinical assessments revealed overall functional improvement (P < .05). After surgery, 11 patients were asymptomatic or presented with only minor neurological deficits. Surgical resection of AVMs in eloquent motor areas can be considered a safe option for selected cases when performed in conjunction with a detailed functional assessment. Possible selection criteria for surgical treatment are discussed in light of the presented clinical data.

A mouse model of human repetitive mild traumatic brain injury

A novel method for the study of repetitive mild traumatic brain injury (rmTBI) that models the most common form of head injury in humans is presented. Existing animal models of TBI impart focal, severe damage unlike that seen in repeated and mild concussive injuries, and few are configured for repetitive application. Our model is a modification of the Marmarou weight drop method and allows repeated head impacts to lightly anesthetized mice. A key facet of this method is the delivery of an impact to the cranium of an unrestrained subject allowing rapid acceleration of the free-moving head and torso, an essential characteristic known to be important for concussive injury in humans, and a factor that is missing from existing animal models of TBI. Our method does not require scalp incision, emplacement of protective skull helmets or surgery and the procedure can be completed in 1–2min. Mice spontaneously recover the righting reflex and show no evidence of seizures, paralysis or impaired behavior. Skull fractures and intracranial bleeding are very rare. Minor deficits in motor coordination and locomotor hyperactivity recover over time. Histological analyses reveal mild astrocytic reactivity (increased expression of GFAP) and increased phospho-tau but a lack of blood–brain-barrier disruption, edema and microglial activation. This new animal model is simple and cost-effective and will facilitate characterization of the neurobiological and behavioral consequences of rmTBI. It is also ideal for high throughput screening of potential new therapies for mild concussive injuries as experienced by athletes and military personnel.

Microsurgical treatment of intracranial thrombotic giant aneurysms( report of 11 cases)

Objective To study the clinical features and surgical management of intracranial thrombotic giant aneurysms.Methods A retrospective study was performed for 11 patients with intracranial thrombotic giant aneurysms.The clinical presentation, clinical classification, surgical approaches and therapeutic efficacy were reviewed.Results The treatment included thrombectomy - aneurysm clip reconstruction in 9 cases, thrombectomy - aneurysm isolate in 1, and cervical internal carotid artery ligation in 1.The postoperative DSA or CTA showed that complete angiographic obliteration was achieved in 10 cases.Follow - up period was from 3 months to 6 months, the clinical outcomes of these patients were evaluated by Glasgow Outcome Scale grades.GOS of 8 cases were improved.There were minor deficit in 1 case, major deficit in 1 and one death.Conclusions The surgical treatment for intracranial thrombotic giant aneurysms is very difficult.It is a good method to occlude the parent artery temporally, eliminate intraaneurysmal thrombus and reconstruct parent artery.Intraoperative microvascular Doppler sonography (MVD) monitoring is helpful. Key words: Intracranial aneurysm; Thrombus; Microsurgical clipping; Thrombectomy

The sensitivity of two-dimensional hindlimb joint kinematics analysis in assessing functional recovery in rats after sciatic nerve crush

Walking analysis in the rat is increasingly used to assess functional recovery after peripheral nerve injury. Here we assess the sensitivity and specificity of hindlimb joint kinematics measures during the rat gait early after sciatic nerve crush injury (DEN), after twelve weeks of recovery (REINN) and in sham-operated controls (Sham) using discriminant analysis. The analysis addressed gait spatiotemporal variables and hip, knee and ankle angle and angular velocity measures during the entire walking cycle. In DEN animals, changes affected all studied joints plus spatiotemporal parameters of gait. Both the spatiotemporal and ankle kinematics parameters recovered to normality within twelve weeks. At this time point, some hip and knee kinematics values were still abnormal when compared to sham controls. Discriminant models based on hip, knee and ankle kinematics displayed maximal sensitivity to identify DEN animals. However, the discriminant models based on spatiotemporal and ankle kinematics data showed a poor performance when assigning animals to the REINN and Sham groups. Models using hip and knee kinematics during walking showed the best sensitivity to recognize the reinnervated animals. The model construed on the basis of hip joint kinematics was the one combining highest sensitivity with robustness and high specificity. It is concluded that ankle joint kinematics fails in detecting minor functional deficits after long term recovery from sciatic nerve crush and extending the kinematic analysis during walking to the hip and knee joints improves the sensitivity of this functional test.

Acute stroke centre - the changing focus of stroke unit care. The Bergen NORSTROKE Study

The basic stroke unit studies selected patients primarily for rehabilitation and did not deal with the critical first hours after stroke. The aim of this study was to analyse a unselected cohort of patients admitted to an acute stroke centre with primary focus on emergency diagnosis and treatment. All patients with suspected stroke were admitted as emergencies. Patients with definite cerebrovascular disease were prospectively included in the Bergen Stroke Study, patients with other diseases were excluded, but final diagnosis was registered. Fifty per cent of the admitted patients had other diagnosis than stroke. Of 1267 consecutive patients with cerebrovascular disease, 70% had no or minor neurological deficits on admission. After 1 week, 56% were independent, 30% needed long-term rehabilitation, 10% were bedridden and 4% were dead. An acute stroke centre today requires a high degree of neurological expertise in assessing patients admitted with possible stroke. Most patients with stroke have no or mild deficits and need above all rapid diagnostic work-up, acute and prophylactic treatment. In-hospital rehabilitation is essential for a smaller number of patients who suffer from persisting neurological deficits after stroke.

Off-Label Thrombolysis for Acute Ischemic Stroke: Rate, Clinical Outcome and Safety Are Influenced by the Definition of ‘Minor Stroke’

Background: Several contraindications for intravenous thrombolysis are not based on controlled trials. Specialized stroke centers often apply less restrictive criteria. The aim of our study was to analyze how many patients at our institution receive off-label thrombolysis. In addition, clinical outcome and safety data were compared to those from patients treated on-label, and the influence of different definitions of ‘minor stroke’ were examined. Methods: Consecutive thrombolysis patients treated between January 2006 and January 2010 were included. Patients treated off-label were compared to patients given on-label therapy according to the European license. Since no specified definition for ‘minor neurological deficit’ exists in the license, two distinct definitions were considered off-label, i.e. National Institutes of Health Stroke Scale score (NIHSSS) <1 (definition 1) and NIHSSS ≤4 (definition 2). Results: Of a total of 422 patients, 232 (55%) were treated off-label. The most prevalent off-label criteria (OLCs) were the following: age >80 years (n = 113), minor stroke (definition 1, n = 3; definition 2, n = 84), elevated blood pressure necessitating aggressive treatment (n = 75), time window >3 h (n = 71) and major surgery or trauma within the preceding 3 months (n = 20). In group comparisons, off-label patients had an overall worse outcome using definition 1 for minor stroke, while there was no difference when definition 2 was applied. In multivariate analysis, off-label therapy (definition 1) in general and age >80 years were independent predictors of poor outcome. None of the contraindications were associated with an increased bleeding risk. Conclusions: Off-label therapy is frequently applied at our center and is not associated with higher complication rates. Overall outcome of off-label treatment largely depends on the definition used for minor stroke. Besides age >80 years, a known poor prognostic factor, no other specific OLC was associated with poor outcome. Our data suggest that the criteria in the European license may be too restrictive.

Age-Related Decline in Circadian Output

Disruptions in sleep/wake cycles, including decreased amplitude of rhythmic behaviors and fragmentation of the sleep episodes, are commonly associated with aging in humans and other mammals. While there are undoubtedly many factors contributing to these changes, a body of literature is emerging, suggesting that an age-related decline in the central circadian clock in the suprachiasmatic nucleus (SCN) may be a key element responsible. To explore age-related changes in the SCN, we have performed in vivo multiunit neural activity (MUA) recordings from the SCN of freely moving young (3-5 months) and middle-aged (13-18 months) mice. Importantly, the amplitude of day-night difference in MUA was significantly reduced in the older mice. We also found that the neural activity rhythms are clearly degraded in the subparaventricular zone, one of the main neural outputs of the SCN. Surprisingly, parallel studies indicate that the molecular clockwork in the SCN as measured by PER2 exhibited only minor deficits at this same age. Thus, the circadian output measured at the level of neural activity rhythms in the SCN is degraded by aging, and this decline occurs before the disruption of key components of the molecular clockwork.