Neurological Examination Findings Research Articles

Prognostic Value of Admission Parameters in a Machine Learning Predictive Model in Patients With Severe Traumatic Brain Injury and Acute Subdural Hematomas

Abstract INTRODUCTION Acute subdural hematoma (aSDH) in the context of severe traumatic brain injury (TBI) is a neurosurgical emergency. Predictive models have been used in an attempt to modulate the morbidity and mortality of patient outcomes. We used machine learning (ML) to identify admission risk factors predictive of long-term morbidity in the severe TBI patient population with aSDH. METHODS Between 2013 and 2016, 85 patients with severe TBI and aSDH were included in the analysis. Random forest, ML architecture, was used to create a predictive model of long-term morbidity stratification. About 46 patients were included in the high morbidity group [Glasgow Outcome Scale (GOS) 1-2] and 39 patients were in the low morbidity group (GOS 3-5). We included 30 admission input variables including medical and surgical co-morbidities, neurological examination, laboratory values, and radiographic findings. RESULTS The predictive model showed a 78% precision. The highest scoring input variable was the pupillary examination in predicting high vs low morbidity (bilaterally unreactive vs symmetrically reactive; P < .0001). GCS on admission was higher in the low morbidity group (4 [3-7] vs 7 [3-7]; P < .0101). Rotterdam scores were higher in the high-morbidity group (3 [3-5] vs 4 [4-5]; P < .0032). GCS motor examination on admission was higher in the low-morbidity group (5 [1-5] vs. 2 [1-5]; P < .0106). The basal cisterns were found to be more patent in patients with the low-morbidity group (P = .0012). CONCLUSION ML is an efficient tool that can provide a reasonable level of accuracy in predicting long-term morbidity in patients with severe TBI and aSDH. Monitoring these admission criteria can help with risk-stratification of patients into higher and low risk tracks. Integration of ML into the treatment algorithm may allow the development of more refined guidelines to guide goal-directed therapy.

Thoracolumbar Evaluation in the Low-Risk Trauma Patient: A Pilot Study Towards Development of a Clinical Decision Rule to Avoid Unnecessary Imaging in the Emergency Department.

Thoracolumbar (TL) injury is a common finding in the severely injured multi-trauma patient. However, the incidence and pattern of TL injury in patients with milder trauma is unclear. The aim of this study was to collect and analyze evidence for the development of a clinical decision rule (CDR) to evaluate the TL spine in patients with non-severe blunt trauma and avoid dedicated imaging in low-risk cases. Adult patients with blunt trauma who presented to a major academic center (May 2016 to October 2017) and received dedicated imaging of the TL spine were included. Exclusion criteria consisted of any coexisting condition preventing the acquisition of history or examination. The primary endpoint is TL spine injury requiring orthopedic evaluation, bracing/orthosis, or surgery. Preliminary CDR derivation was performed with recursive partitioning. Of 4612 patients screened, 1049 (22.7%) met inclusion criteria. Thirty-six (3.4%) patients were found to have TL spine injury, of which 88.9% received spinal bracing, orthosis, or surgery. Absence of midline tenderness conveyed the highest negative predictive value, followed by a non-severe mechanism of injury, lack of neurologic examination findings, and age < 65years. No patients in this cohort with these four findings had a TL spine injury. In certain lower-risk blunt trauma patients < 65years of age, focused examination combined with mechanism of injury may be highly sensitive (100%) to rule out TL injury without the need for dedicated imaging. However, validation is necessary, given multiple study limitations. Potential instrument to screen for TL injury in minor trauma: TL injury is unlikely if all four of the following are present: 1) no midline back tenderness or deformity, 2) no focal neurologic signs or symptoms or altered mentation, 3) age < 65years; and 4) lack of severe mechanism of injury, for example, fall greater than standing, motor-vehicle collision with rollover/ejection/pedestrian or unenclosed vehicle, and assault with a weapon.

Does the Neurological Examination Correlate with Patient-Perceived Outcomes in Degenerative Cervical Myelopathy?

In patients with neurological disorders, a divergence can exist between patients' perceptions regarding the outcomes and the objective neurological findings. Degenerative cervical myelopathy (DCM), a prevalent condition characterized by progressive compression of the cervical spinal cord, can produce debilitating symptoms and profound neurological findings. The purpose of the present study was to determine whether the physician-derived neurological examination findings, as recorded by American Spine Injury Association (ASIA) summary score, correlated with the patient-derived outcome measures for DCM. A total of 78 patients underwent surgical management of DCM with completion of preoperative and 6-month follow-up assessments. Surgical management consisted of either anterior or posterior cervical decompression. All patients underwent a neurological evaluation, including an ASIA assessment before surgery and 6 months after surgery, and completed the modified Japanese Orthopaedic Association (mJOA), neck disability index (NDI), and Short-Form 36-item (SF-36) scales pre- and postoperatively to measure both disease-specific and general perceived outcomes. The objective physician-derived neurological testing (ASIA) did not correlate with the patient-derived scales (mJOA, NDI, and SF-36) pre- or postoperatively. Patients reported significant improvements (P <0.001) at 6 months postoperatively in extremity functioning (mJOA), neck pain (NDI), overall physical health (SF-36), and objective strength and sensory functioning (ASIA). All patient-perceived outcome measures correlated with each other pre- and postoperatively (P < 0.01). Objective scoring of postoperative neurological function did not correlate with patient-perceived outcomes before and after surgery for DCM. Traditional testing of motor and sensory function as part of the neurological assessment may not be sensitive enough to assess the scope of neurological changes experienced by patients with DCM.

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Anti-NMDA-receptor antibody in initial diagnosis of mood disorder

Anti-NMDAR encephalitis is increasingly recognized as one etiology of psychiatric symptoms, but there is not enough evidence on patients with mood disorder. We assayed anti-NR1/NR2B IgG antibodies in serum and/or cerebrospinal fluid of 62 patients initially diagnosed with mood disorder by a cell-based assay. We also investigated the specific patient characteristics and psychotic symptoms. At first admission, the patients showed only psychiatric symptoms without typical neurological signs or abnormal examination findings. Four of the 62 patients had anti-NR1/NR2B IgG antibodies. The anti-NR1/NR2B IgG antibody-positive patients showed more super- or abnormal sensitivity (P = 0.00088), catatonia (P = 0.049), and more conceptual disorganization (P < 0.0001), hostility (P = 0.0010), suspiciousness (P < 0.0001), and less emotional withdrawal (P < 0.0001) and motor retardation (P < 0.0001) on the Brief Psychiatric Rating Scale than the antibody-negative patients. During the clinical course, anti-NR1/NR2B IgG antibody-positive patients showed more catatonia (P = 0.0042) and met Graus's criteria for diagnosis of anti-NMDAR encephalitis, but negative patients did not. Immunotherapy was effective for anti-NR1/NR2B IgG antibody-positive patients, and there was the weak relationship (R² = 0.318) between the anti-NR1/NR2B IgG antibody titer in the cerebrospinal fluid and the Brief Psychiatric Rating Scale score.

The neurologic phenotype of South African patients with HIV-associated neurocognitive impairment.

The neurologic manifestations of HIV include a spectrum of HIV-associated neurocognitive disorders, as well as a cluster of neurologic symptoms and signs. The neurologic manifestations have been modified but not eradicated by antiretroviral therapy (ART). We describe the neurologic phenotype in South African patients with predominant HIV-1 subtype C infection on ART and its association with neurocognitive impairment and efavirenz and 8-hydroxy-efavirenz concentrations. We conducted a cross-sectional analysis of the neurologic examination findings of HIV+ patients with neurocognitive impairment and used multiple linear regression to explore associations with neurocognitive impairment, efavirenz, and 8-hydroxy-efavirenz pharmacokinetics (plasma and CSF). We included 80 participants established on ART (median 40 months) of which 72 (90%) were female. The median age was 35 (interquartile range [IQR], 32-42) and the median Global Deficit Score was 0.94 (IQR 0.63-1.36). We found associations between neurocognitive impairment and neurologic signs: gait (slow walking speed [p = 0.03; R2 = 0.06], gait ataxia [p < 0.01; R2 = 0.21], and abnormal gait appearance [p < 0.01; R2 = 0.18]); coordination (upper limb bradykinesia [p < 0.01; R2 = 0.10] and lower limb bradykinesia [p = 0.01; R2 = 0.10]); reflexes (jaw jerk [p = 0.04; R2 = 0.05] and palmomental response [p = 0.03; R2 = 0.06]); ocular signs (impaired smooth pursuit [p = 0.01; R2 = 0.09] and impaired saccades [p < 0.01; R2 = 0.15]); and motor signs (spasticity [p ≤ 0.01; R2 = 0.15] and muscle weakness [p = 0.01; R2 = 0.08]). No significant associations were found between plasma and CSF efavirenz or 8-hydroxy efavirenz concentrations and any neurologic sign. We found that individual neurologic signs were associated with neurocognitive impairment in South African HIV+ patients with predominant HIV-1 subtype C infection on ART and could be used in clinical practice to assess severity. PACTR201310000635418.

Clinical Findings, Treatments and Outcomes in Farm Animals with Vertebral Fractures or Luxations: 22 Cases (2006-2017).

The aim of this study was to describe the signalment, clinical presentation, diagnostic findings, medical and surgical treatment and outcome of 22 farm animals diagnosed with a vertebral fracture or luxation. Medical records of 22 farm animals (7 goats, 6 alpacas, 5 cattle, 3 sheep and 1 deer) were reviewed for signalment, history, presenting clinical signs and neurological examination findings, clinicopathological results, diagnostic imaging, final diagnosis, medical and surgical management, clinical progression and outcome. Animals' age ranged from 1 day to 15 years. Neurological examination findings included decreased motor function (20/22), recumbency (14/22), altered mentation (13/22), cranial nerve deficits (4/22) and lack of nociception (3/22). Lesions were localized to the atlanto-occipital region (2/22), C1 to C5 (7/22), C6 to T2 (4/22), T3 to L3 (3/22), and L4 to S1 (6/22). Diagnoses included vertebral fracture only (4/22), luxation only (5/22) or both vertebral fracture and luxation (13/22). In five cases, no therapy was attempted, while 12 cases were treated medically and five cases were treated surgically. Surgical interventions included manual reduction (n = 1); arthrodesis (n = 2); laminectomy (n = 1); and laminectomy with pin fixation, cerclage wire and polymethylmethacrylate bridging (n = 1). Five of the 22 cases survived to hospital discharge; two of these were treated surgically. The cervical region was most commonly affected. Prognosis for these injuries in farm animals is guarded.

Neurologic Examination Findings Associated With Small Cerebellar Volumes After Prematurity

To help clinicians understand what to expect from small cerebellar volumes after prematurity, this study aims to characterize the specific impacts of small cerebellar volumes on the infant neurologic examination. A prospective cohort of preterm newborns (<32 weeks' gestational age) had brain magnetic resonance imaging (MRI) studies at term-equivalent age. Cerebellar volumes were compared with neurologic examination findings in follow-up, adjusting for severity of intraventricular hemorrhage, white matter injury, and cerebellar hemorrhage. Deformation-based analyses delineated regional morphometric differences in the cerebellum associated with these findings. Of 119 infants with MRI scans, 109 (92%) had follow-up at 19.0±1.7 months corrected age. Smaller cerebellar volume at term was associated with increased odds of truncal hypotonia, postural instability on standing, and patellar hyperreflexia (P < .03). Small cerebellar volume defined as <19 cm3 by 40 weeks was associated with 7.5-fold increased odds of truncal hypotonia (P < .001), 8.9-fold odds postural instability (P < .001), and 9.7-fold odds of patellar hyperreflexia (P < .001). Voxel-based deformation-based morphometry showed postural instability associated with paravermian regions. Small cerebellar volume is associated with specific abnormalities on neurologic examination by 18 months of age, including truncal tone, reflexes, and postural stability.

Prevalence of electrographic seizure in dogs and cats undergoing electroencephalography and clinical characteristics and outcome for dogs and cats with and without electrographic seizure: 104 cases (2009-2015).

To determine the prevalence of electrographic seizure (ES) and electrographic status epilepticus (ESE) in dogs and cats that underwent electroencephalography (EEG) because of suspected seizure activity and to characterize the clinical characteristics, risk factors, and in-hospital mortality rates for dogs and cats with ES or ESE. Retrospective case series. 89 dogs and 15 cats. Medical records of dogs and cats that underwent EEG at a veterinary neurology service between May 2009 and April 2015 were reviewed. Electrographic seizure was defined as ictal discharges that evolved in frequency, duration, or morphology and lasted at least 10 seconds, and ESE was defined as ES that lasted ≥ 10 minutes. Patient signalment and history, physical and neurologic examination findings, diagnostic test results, and outcome were compared between patients with and without ES or ESE. Among the 104 patients, ES and ESE were diagnosed in 21 (20%) and 12 (12%), respectively. Seventeen (81%) patients with ES had no or only subtle signs of seizure activity. The in-hospital mortality rate was 48% and 50% for patients with ES and ESE, respectively, compared with 19% for patients without ES or ESE. Risk factors for ES and ESE included young age, overt seizure activity within 8 hours before EEG, and history of cluster seizures. Results indicated that ES and ESE were fairly common in dogs and cats with suspected seizure activity and affected patients often had only subtle clinical signs. Therefore, EEG is necessary to detect patients with ES and ESE.

Results of oral prednisolone administration or ventriculoperitoneal shunt placement in dogs with congenital hydrocephalus: 40 cases (2005-2016).

To evaluate signalment, clinical findings, and outcomes of dogs with congenital hydrocephalus treated medically with orally administered prednisolone or surgically by ventriculoperitoneal shunt placement. Retrospective case series. 40 client-owned dogs. Medical records from 2005 to 2016 were searched to identify dogs with congenital hydrocephalus confirmed by MRI examination. Patients were categorized by treatment (medical vs surgical). Signalment, clinical signs, neurologic examination findings, results of diagnostic tests, duration of hospitalization, complications potentially related to treatment, and follow-up information were recorded. Outcome was categorized on the basis of clinical (neurologic) signs as improved, stabilized, or deteriorated. Variables of interest were compared between groups by Fisher exact or Mann-Whitney U tests. 28 and 12 dogs had surgical and medical treatment, respectively; 3 medically treated dogs subsequently underwent ventriculoperitoneal shunt placement. No significant differences were noted in clinical or imaging findings between surgically and medically treated dogs. Median follow-up time was 9 months and 15.5 months for medically and surgically treated dogs, respectively. Of 12 medically treated dogs, 6 improved and 6 deteriorated. Of 26 surgically treated dogs with data available, 14 (54%) improved, 1 (4%) stabilized, and 11 (42%) deteriorated; 4 (15%) had known postoperative complications. Approximately half of the dogs treated with prednisolone in this population had neurologic improvement at last follow-up; results of surgical treatment were comparable to those in previous studies. Further research is needed to assess factors associated with acceptable outcomes for dogs with congenital hydrocephalus.

Minicraniotomy with a subgaleal pocket for the treatment of subdural fluid collections in infants.

Various surgical techniques have been described to treat subdural fluid collections in infants, including transfontanelle aspiration, burr holes, subdural drain, subduroperitoneal shunt, and minicraniotomy. The purpose of this study was to describe a modification of the minicraniotomy technique that avoids the implantation of external drainage catheters and potentially carries a higher success rate. In this retrospective study, the authors describe 11 cases involving pediatric patients who underwent parietal minicraniotomies for the evacuation of subdural fluid collections. In contrast to cases previously described in the literature, no patient received a drain; instead, a subgaleal pocket was created such that the fluid could flow from the subdural to the subgaleal space. Preoperative and postoperative data were reviewed, including neurological examination findings, radiological findings, complications, hospital length of stay, and findings on follow-up examinations and imaging. The primary outcome was failure of the treatment strategy, defined as an increase in subdural fluid collection requiring further intervention. Eleven patients (8 boys and 3 girls, median age 4.5 months) underwent the described procedure. Eight of the patients had complete resolution of the subdural collection on follow-up imaging, and 2 had improvement. One patient had a new subdural collection due to a second injury. Only 1 patient underwent aspiration and subsequent surgical repair of a pseudomeningocele after the initial surgery. Notably, no patients required subduroperitoneal shunt placement. The authors describe a new surgical option for subdural fluid collections in infants that allows for more aggressive evacuation of the subdural fluid and eliminates the need for a drain or shunt placement. Further work with more patients and direct comparison to other alternative therapies is necessary to fully evaluate the efficacy and safety of this new technique.

Intracranial subdural empyemas and epidural abscesses in children

The authors conducted a retrospective analysis of a consecutive series of children with intracranial subdural empyemas (SEs) and epidural abscesses (EAs) to highlight the important clinical difference between these two entities. They describe the delays and pitfalls in achieving accurate diagnoses and make treatment recommendations based on clinical and imaging findings. They reviewed their experience with children who had presented with intracranial SE and/or EA in the period from January 2013 to May 2018. They recorded presenting complaint, date of presentation, age, neurological examination findings, time from presentation to diagnosis, any errors in initial image interpretation, timing from diagnosis to surgical intervention, type of surgical intervention, neurological outcome, and microbiology data. They aimed to assess possible causes of any delay in diagnosis or surgical intervention. Sixteen children with SE and/or EA had undergone evaluation by the authors’ neurosurgical service since 2013. Children with SE (n = 14) presented with unmistakable evidence of CNS involvement with only one exception. Children with EA alone (n = 2) had no evidence of CNS dysfunction. All children older than 1 year of age had sinusitis. The time from initial presentation to a physician to diagnosis ranged from 0 to 21 days with a mean and median of 4.5 and 6 days, respectively. The time from diagnosis to neurosurgical intervention ranged from 0 to 14 days with a mean and median of 3 and 1 day, respectively. Delay in treatment was due to misinterpretation of images, a failure to perform timely imaging, progression on imaging as an indication for surgical intervention, or the managing clinician’s preference. Among the 14 cases with SE, initial imaging studies in 6 were not interpreted as showing SE. Four SE collections were dictated as epidural even on MRI. The only fatality was associated with no surgical intervention. Endoscopic sinus surgery was not associated with reducing the need for repeat craniotomy. Regardless of the initial imaging interpretation, any child presenting with focal neurological deficit or seizures and sinusitis should be assumed to have an SE or meningitis, and a careful review of high-resolution imaging, ideally MRI with contrast, should be performed. If an extraaxial collection is identified, surgical drainage should be performed expeditiously. Neurosurgical involvement and evaluation are imperative to achieve timely diagnoses and to guide management in these critically ill children. EA = epidural abscess; SE = subdural empyema.

Comparative study on clinical, laboratory and electrodiagnostic findings of peripheral neuropathy in patients with hypocupremia and hypercupremia, and literature review

Copper deficiency (hypocupremia) or toxicosis (hypercupremia) may cause disorders of central and peripheral nervous systems. Hypocupremia causes myeloneuropathy resembling vitamin B12 deficiency. However, the clinical manifestations, particularly peripheral neuropathy (PN), of hypercupremia have not been adequately evaluated. To compare clinical, laboratory and electrodiagnositc features of PN between patients with hypocupremia and hypercupremia, we retrospectively reviewed the charts of patients with abnormal copper levels. Subjects with zinc abnormalities were excluded. Five hypocupremia (Male/Female = 4/1; age: 54.6 ± 17.1 years; copper = 55.0 ± 8.5 μg/dL [normal = 72–175]; zinc = 74.4 ± 15.5 μg/dL [normal = 60–130]) and 3 hypercupremia (M/F = 1/2; age: 57.0 ± 8.2 years; copper = 215.0 ± 10.8 μg/dL; zinc = 72.3 ± 14.6 μg/dL) were studied. The notable clinical findings included ambulatory difficulty in hypocupremia (2/5); paresthesia in both hypocupremia (3/5) and hypercupremia (2/3) but pain was only seen in (3/3) hypercupremia patients. Tendon reflexes were decreased in hypocupremia (3/5) and hypercupremia (1/3) but hyperreflexias in hypocupremia (2/5) only. Preexisting comorbidity such as diarrhea were observed in (2/3) hypercupremia but not in hypocupremia patients. Laboratory findings showed vitamin D deficiency (16.4 ± 5.6 ng/mL) in (2/2) hypercupremia but normal (40.4 ± 4.7 ng/mL) in (2/2) hypocupremia. Neurophysiologic studies showed evidence of neuropathy in (3/5) hypocupremia only. Different patterns of clinical, neurological examination and electrophysiologic findings between hypocupremia and hypercupremia suggest different underlying pathophysiologies.

3-Tesla MRI of deep brain stimulation patients: safety assessment of coils and pulse sequences.

Physicians are more frequently encountering patients who are treated with deep brain stimulation (DBS), yet many MRI centers do not routinely perform MRI in this population. This warrants a safety assessment to improve DBS patients' accessibility to MRI, thereby improving their care while simultaneously providing a new tool for neuromodulation research. A phantom simulating a patient with a DBS neuromodulation device (DBS lead model 3387 and IPG Activa PC model 37601) was constructed and used. Temperature changes at the most ventral DBS electrode contacts, implantable pulse generator (IPG) voltages, specific absorption rate (SAR), and B1+rms were recorded during 3-T MRI scanning. Safety data were acquired with a transmit body multi-array receive and quadrature transmit-receive head coil during various pulse sequences, using numerous DBS configurations from "the worst" to "the most common."In addition, 3-T MRI scanning (T1 and fMRI) was performed on 41 patients with fully internalized and active DBS using a quadrature transmit-receive head coil. MR images, neurological examination findings, and stability of the IPG impedances were assessed. In the phantom study, temperature rises at the DBS electrodes were less than 2°C for both coils during 3D SPGR, EPI, DTI, and SWI. Sequences with intense radiofrequency pulses such as T2-weighted sequences may cause higher heating (due to their higher SAR). The IPG did not power off and kept a constant firing rate, and its average voltage output was unchanged. The 41 DBS patients underwent 3-T MRI with no adverse event. Under the experimental conditions used in this study, 3-T MRI scanning of DBS patients with selected pulse sequences appears to be safe. Generally, T2-weighted sequences (using routine protocols) should be avoided in DBS patients. Complementary 3-T MRI phantom safety data suggest that imaging conditions that are less restrictive than those used in the patients in this study, such as using transmit body multi-array receive coils, may also be safe. Given the interplay between the implanted DBS neuromodulation device and the MRI system, these findings are specific to the experimental conditions in this study.

Medical photography with a mobile phone: useful techniques, and what neurosurgeons need to know about HIPAA compliance.

Medical photographs are commonly employed to enhance education, research, and patient care throughout the neurosurgical discipline. Current mobile phone camera technology enables surgeons to quickly capture, document, and share a patient scenario with colleagues. Research demonstrates that patients generally view clinical photography favorably, and the practice has become an integral part of healthcare. Neurosurgeons in satellite locations often rely on residents to send photographs of diagnostic imaging studies, neurological examination findings, and postoperative wounds. Images are also frequently obtained for research purposes, teaching and learning operative techniques, lectures and presentations, comparing preoperative and postoperative outcomes, and patient education. However, image quality and technique are highly variable. Capturing and sharing photographs must be accompanied by an awareness of the legal ramifications of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA compliance is straightforward when one is empowered with the knowledge of what constitutes a patient identifier in a photograph. Little has been published to describe means of improving the accuracy and educational value of medical photographs in neurosurgery. Therefore, in this paper, the authors present a brief discussion regarding four easily implemented photography skills every surgeon who uses his or her mobile phone for patient care should know: 1) provide context, 2) use appropriate lighting, 3) use appropriate dimensionality, and 4) manage distracting elements. Details of the HIPAA-related components of mobile phone photographs and patient-protected health information are also included.

Incidence of multiple sclerosis misdiagnosis in referrals to two academic centers

BackgroundMultiple Sclerosis (MS) specialists routinely evaluate misdiagnosed patients, or patients incorrectly assigned a diagnosis of MS. Misdiagnosis has significant implications for patient morbidity and healthcare costs, yet its contemporary incidence is unknown. We examined the incidence of MS misdiagnosis in new patients referred to two academic MS referral centers, their most common alternate diagnoses, and factors associated with misdiagnosis. MethodsDemographic data, comorbidities, neurological examination findings, radiographic and laboratory results, a determination of 2010 McDonald Criteria fulfillment, and final diagnoses were collected from all new patient evaluations completed at the Cedars-Sinai Medical Center and the University of California, Los Angeles MS clinics over twelve months. ResultsOf the 241 new patients referred with an established diagnosis of MS, 17% at Cedars-Sinai and 19% at UCLA were identified as having been misdiagnosed. The most common alternative diagnoses were migraine (16%), radiologically isolated syndrome (9%), spondylopathy (7%), and neuropathy (7%). Clinical syndromes and radiographic findings atypical for MS were both associated with misdiagnosis. The misdiagnosed group received approximately 110 patient-years of unnecessary MS disease modifying therapy. ConclusionMS misdiagnosis is common; in our combined cohort, almost 1 in 5 patients who carried an established diagnosis of MS did not fulfill contemporary McDonald Criteria and had a more likely alternate diagnosis.

Risk factors for seizure recurrence in a pediatric observation unit

BackgroundMost patients present with seizures to pediatric emergency department (PED) are observed for extended periods for the risk of possible acute recurrence. ObjectiveThe aim of this study is to determine the risk factors of acute recurrence within first 24 h. MethodsPatients who presented to PED with seizure during past 24 h were enrolled. Demographic features, number and duration of seizures, diagnostic studies, physical examination findings, presence and time of seizure recurrence in PED were noted. Results187 patients were eligible for the study. 46% had recurrence of seizures in 24 h, 90,8% of recurrence within the first 6 h. Univariate analysis showed that younger patients, epileptic patients who were on multiple antiepileptic drugs (AEDs), who had multiple seizures during the past 24 h, who had abnormal neurological examination or neuroimaging findings had increased risk of seizure recurrence. Multivariate analysis showed that number of seizures during the past 24 h and previous use of AEDs was significantly associated with increased risk of recurrence. ConclusionRisk factors for acute recurrence should be evaluated for each patient. Patients without risk factors and no seizures during the first 6 h should not be observed for extended periods in PED.

Lumbar Juxtafacet Cysts.

To evaluate the factors affecting the clinical and radiological findings of juxtafacet cyst patients. Between January 2011 and December 2018, eight patients diagnosed with juxtafacet cyst were reviewed, retrospectively. Patient demographics; signs and symptoms; and neurological examination, radiological, and surgical findings were noted. The mean age was 54 years (range, 34â€"69 years) with five (62.5%) females and three (37.5%) males. There were nine juxtafacet cysts in eight patients. Five cysts (55.5%) were located at the L3â€"L4 level, two cysts (22.2%) at the L4â€"L5 level, and two cysts (22.2%) at the L5â€"S1 level. In all patients with L3â€"L4 cysts, the intercrest line was intersecting the spinal column at L4 vertebral body level. The most frequent symptoms were back pain and radiculopathy. Magnetic resonance imaging and computerized tomography revealed degenerative facet arthropathy in six patients (75%). Three patients (37.5%) had a medical history of trauma. One patient (12.5%) was treated conservatively. Seven patients (87.5%) were advised to undergo surgical treatment. Degeneration and instability are the main causes of juxtafacet cysts. They are mainly seen at the L4â€"L5 level due to higher movement capacity of this level. But, if the intercrest line intersects the spinal column at higher levels, degeneration and instability risks move to upper levels, and juxtafacet cysts may occur at the L3â€"L4 or upper levels.

BILATERAL SUBDURAL HEMATOMA AFTER VENTRICULOPERITONEAL SHUNT SURGERY

Introduction: Bilateral subdural hematoma (SDH) following ventriculoperitoneal&#x0D; (V/P) shunt application was discussed in present case.Case Report: 8-year-old girl was operated due to thoracolumbar meningomyelocele&#x0D; immediately after birth. V/ P shunt was inserted in right posterior parietal&#x0D; region due to hydrocephalus when she was 3 month-old. At age of 3 years, V/P shunt&#x0D; dysfunction was considered, and second V/P shunt was inserted in left posterior&#x0D; parietal region. One year after, patient was reevaluated, and CT images showed&#x0D; bilateral subacute SDH. &amp;nbsp;Hematoma evacuation&#x0D; was not considered, but right ventricular catheter was ligated. At four years&#x0D; follow-up, no additional neurological impairment was observed in patient and CT&#x0D; scan revealed that SDHs were retracted greatly.Concusion:&#x0D; It should be&#x0D; kept in mind that SDH could develop after V/P shunt surgery. Additionally, it&#x0D; could be said that one of most important factor in determination of treatment&#x0D; of this complication was primarily neurological examination findings of&#x0D; patient.

Comprehensive Evaluation of Healthy Volunteers Using Multi-Modality Brain Injury Assessments: An Exploratory, Observational Study.

Introduction: Even though mild traumatic brain injury is common and can result in persistent symptoms, traditional measurement tools can be insensitive in detecting functional deficits after injury. Some newer assessments do not have well-established norms, and little is known about how these measures perform over time or how cross-domain assessments correlate with one another. We conducted an exploratory study to measure the distribution, stability, and correlation of results from assessments used in mild traumatic brain injury in healthy, community-dwelling adults.Materials and Methods: In this prospective cohort study, healthy adult men and women without a history of brain injury underwent a comprehensive brain injury evaluation that included self-report questionnaires and neurological, electroencephalography, sleep, audiology/vestibular, autonomic, visual, neuroimaging, and laboratory testing. Most testing was performed at 3 intervals over 6 months.Results: The study enrolled 83 participants, and 75 were included in the primary analysis. Mean age was 38 years, 58 were male, and 53 were civilians. Participants did not endorse symptoms of post-concussive syndrome, PTSD, or depression. Abnormal neurological examination findings were rare, and 6 had generalized slowing on electroencephalography. Actigraphy and sleep diary showed good sleep maintenance efficiency, but 21 reported poor sleep quality. Heart rate variability was most stable over time in the sleep segment. Dynavision performance was normal, but 41 participants had abnormal ocular torsion. On eye tracking, circular, horizontal ramp, and reading tasks were more likely to be abnormal than other tasks. Most participants had normal hearing, videonystagmography, and rotational chair testing, but computerized dynamic posturography was abnormal in up to 21% of participants. Twenty-two participants had greater than expected white matter changes for age by MRI. Most abnormal findings were dispersed across the population, though a few participants had clusters of abnormalities.Conclusions: Despite our efforts to enroll normal, healthy volunteers, abnormalities on some measures were surprisingly common.Trial Registration: This study was registered at www.clinicaltrials.gov, trial identifier NCT01925963.