Neurological Examination Findings Research Articles

Incidence of and risk factors for major complications or death in dogs undergoing cytoreductive surgery for treatment of suspected primary intracranial masses.

OBJECTIVE To determine incidence of and risk factors for major complications occurring in dogs within 30 days after cytoreductive surgery performed by a single pair of surgeons for treatment of suspected primary intracranial masses. DESIGN Retrospective cohort study. ANIMALS 160 client-owned dogs that underwent cytoreductive surgery for treatment of suspected primary intracranial masses between January 2009 and December 2015 at a veterinary teaching hospital. PROCEDURES Medical records were retrospectively reviewed for complications occurring within 30 days after surgery. Data (eg, signalment, clinical signs, previous treatments, preoperative neurologic examination findings, neuroanatomical location, time from onset of clinical signs to surgery, surgical approach, and histopathologic diagnosis) were analyzed for associations with death and with development of major complications other than death. RESULTS 21 (13.1%) dogs died (11 during hospitalization and 10 after discharge) and 30 (18.8%) developed major complications other than death during the first 30 days after surgery. Dogs with abnormal preoperative neurologic examination findings were more likely to develop complications or die. Dogs undergoing a suboccipital approach were more likely to die. The most common postoperative complications other than death were seizures (n = 18 [11.3%]), worsening of neurologic status (6 [3.8%]), and aspiration pneumonia (6 [3.8%]). CONCLUSIONS AND CLINICAL RELEVANCE Results of the present study provided valuable information on predisposing factors, odds of major complications or death, and incidences of major complications or death in dogs during the first 30 days after undergoing cytoreductive surgery for treatment of suspected primary intracranial masses. Careful case selection may help improve outcomes and minimize complications.

341. Characteristics, Risk Factors, and Outcomes of Encephalitis in Older Adults

BackgroundEncephalitis is a serious medical condition with adverse clinical outcomes seen in 50% of individuals. Older adults have higher rates of adverse outcomes in community-acquired meningitis but studies in encephalitis are lacking.MethodsA multicenter retrospective chart review of adults with encephalitis as defined by the international encephalitis consortium between 2000 and 2017 at 19 hospitals in New Orleans, Louisiana and Houston, Texas. Patients were classified as younger adults (<65 years) and older adults (≥ 65 years of age).ResultsA total of 340 adults were enrolled; 71 (21%) with possible and 268 (79%) with probable or confirmed encephalitis. An etiology was documented in 151 (44.5%) cases with the most common causes being arboviruses (17%); Herpes simplex virus(HSV)(16.5%), and anti-N-methyl-d-aspartate receptor antibody (13.4%). A total of 62 (18.3%) were older adults. Older adults were more likely than younger adults to have comorbidities, a vesicular or petechial rash, abnormalities on head computerized tomography scan, and to have a positive HSVpolymerase chain reaction (PCR) and a positive arboviral serology (P < 0.05). Older adults were also less likely to have human immunodeficiency virus (P = 0.004) and to receive adjunctive steroids (32.4% vs. 60.8%, P = 0.002). There were no significant differences between older and younger adults regarding symptoms, neurological examination findings, CSF profile, use of empiric antibiotic and antiviral therapy, and need for mechanical ventilation or intensive care unit admission (P > 0.2). Older adults were also more likely to have an adverse clinical outcome than younger adults (65% vs. 50.5%, P = 0.04).ConclusionOlder adults with encephalitis more commonly have HSV and arboviruses and have higher rates of adverse clinical outcomes despite having similar clinical presentations.Disclosures All authors: No reported disclosures.

Predictive Value of Midline Spikes on Pediatric EEG for Seizure and Developmental Outcome.

Midline spikes are epileptiform discharges localized to the midsagittal regions of the brain. Isolated midline spikes are rare, but more common in children. Our objective was to determine whether midline spikes are predictive of seizure characteristics and neurodevelopment. EEGs and clinical information of 123 children with isolated midline spikes, and EEG follow-up within 12 to 24 months, were reviewed and compared with controls. Most children with midline spikes had seizures (91%), with an equal predisposition to focal or generalized seizure semiology. There was no difference between the midline spike and control groups in terms of neonatal complications, seizure characteristics (type, frequency, and etiology), and neurologic examination findings. In patients with abnormal neuro-maging, deep gray or white matter abnormalities were more frequent in the midline group (41% vs. 13%, P = 0.02). The midline group had a higher risk of development delay (DD) than controls (43% vs. 29%, odds ratio: 1.8, 95% CI [1.1-3.2], P = 0.03). A higher risk of DD was also noted in the midline group in those aged less than 4 years (52% vs. 26%, odds ratio: 3.1, 95% CI [1.0-9.2], P = 0.04) and in those without seizures (40% vs. 17%, odds ratio: 3.16, 95% CI [1.1-8.8], P = 0.03). This is the largest reported group of patients with midline spikes. Midline spikes have a strong association with seizures and DD. Our data suggest that midline spikes result from heterogeneous etiologies, are more common in young children, and are not benign.

A novel form of intracranial coccidioidomycosis is present in dogs and exhibits characteristic clinical and magnetic resonance imaging findings

The neurological examination findings, clinical pathology (including Coccidioides immitis IgG/IgM serology) and magnetic resonance imaging (MRI) findings in 13 dogs with a novel form of intracranial coccidioidomycosis are described in a retrospective case series, with long-term clinical resolution documented in 11/13 dogs (84.6% of cases) with oral fluconazole therapy. The medical records of the Veterinary Neurological Center in Phoenix, Arizona from the years 2000 to 2017 were utilized to search for dogs with appropriate inclusion criteria. Magnetic resonance imaging findings were highly consistent across all cases and characteristically demonstrated bilaterally symmetric T2 hyperintensity throughout the frontal lobes, caudate nuclei, and rostral internal capsule, ±faint, wispy contrast enhancement on T1-postcontrast images. These findings were in stark contrast to previously reported MRI findings in dogs with intracranial coccidioidomycosis, which were typically characterized by a focal, strongly contrast enhancing granuloma and extensive vasogenic edema, typically unilateral. Schnauzer breeds represented eight of 13 (61.5%) cases, possibly suggesting a breed predilection. Three cases underwent repeat MRI after resolution of neurological signs and documentation of a decreased Coccidioides titer in response to fluconazole therapy. All demonstrated complete resolution of previously identified lesions, but with marked, severe atrophy of the caudate nuclei and frontal lobes bilaterally. Findings from this study document a variant appearance for intracranial coccidioidomycosis that, to the author's knowledge, has not been previously described in dogs. Authors propose that, although this variant demonstrates extensive pathological changes within the forebrain, the clinical outcome and response to treatment is favorable in a majority of cases.

Outcomes of nonsurgical treatment for congenital thoracic vertebral body malformations in dogs: 13 cases (2009-2016).

OBJECTIVE To characterize outcomes following nonsurgical treatment of congenital thoracic vertebral body malformations causing neurologic deficits in dogs. DESIGN Retrospective case series. ANIMALS 13 client-owned dogs treated nonsurgically for congenital thoracic vertebral body malformations at 3 veterinary referral hospitals from June 2009 through May 2016. PROCEDURES Data were extracted from the medical records regarding dog signalment, duration and type of clinical signs before referral, general physical and neurologic examination findings, radiographic and MRI findings, and treatments provided after diagnosis. Follow-up data were obtained from records of recheck examinations and via a standardized owner questionnaire. RESULTS All included dogs were screw-tail brachycephalic breeds with a median age of 6 months. All dogs had ambulatory paraparesis and ataxia, and in 1 dog, signs of spinal hyperesthesia could be elicited. Nonsurgical treatments consisted of restricted exercise without (n = 5) or with (3) physiotherapy, physiotherapy without restricted exercise (3), and no exercise modification (2). Seven dogs received additional nonsurgical treatment consisting of prednisolone (n = 5) or gabapentin (2). Four dogs were eventually euthanized because of progressive neurologic deterioration, 2 underwent surgery for the same reason, and the remaining 7 dogs survived for ≥ 170 days after diagnosis, despite progressive neurologic deterioration. CONCLUSIONS AND CLINICAL RELEVANCE Nonsurgical treatment of congenital thoracic vertebral body malformations was associated with an unfavorable outcome in this group of dogs. Despite this treatment, all dogs had progression of clinical signs.

Wharton’s Jelly-Derived Mesenchymal Stem Cell Transplantation in a Patient with Hypoxic-Ischemic Encephalopathy

Wharton’s jelly-derived mesenchymal stem cells (WJ-MSCs) have been introduced as a possible therapy in hypoxic-ischemic encephalopathy (HIE). We report a 16-year-old boy who was treated with WJ-MSCs in the course of HIE due to post-cardiopulmonary resuscitation. He received a long period of mechanical ventilation and tracheostomy with spastic quadriparesis. He underwent the intrathecal (1×106/kg in 3 mL), intramuscular (1×106/kg in 20 mL) and intravenous (1×106/kg in 30 mL) administrations of WJ-MSCs for each application route (twice a month for 2 months). After stem cell infusions, progressive improvements were shown in his neurological examination, neuroradiological, and neurophysiological findings. To our best knowledge, this is a pioneer project to clinically study the neural repair effect of WJ-MSCs in a patient with HIE.

Bilateral oculomotor ocular neuromyotonia: a case report

BackgroundOcular neuromyotonia (ONM) is characterized by episodic diplopia, which is usually triggered by prolonged eccentric gaze of the affected extraocular muscles. The spell is characterized by involuntary, occasionally painful, sustained contraction of one or more extraocular muscles innervated by the oculomotor, trochlear, or abducens nerve. ONM usually occurs as a late consequence of radiotherapy around the parasellar area, although idiopathic cases have been reported. Most cases are unilateral; however, bilateral ONM has occasionally been described.Case presentationA 60-year-old woman presented with a 4-month history of episodic, painful, horizontal binocular diplopia. She underwent external beam radiotherapy to the skull base for treatment of nasopharyngeal carcinoma. The tumor was well controlled. General neurological examination findings were unremarkable. Neuro-ophthalmic examination revealed normal visual acuity, visual fields, pupils, and fundi. Ocular alignment showed orthotropia with normal ocular motility. Myasthenic eyelid signs were absent. However, she developed episodes of involuntary sustained contraction of the medial rectus muscle following prolonged eccentric gaze toward the affected medial rectus muscle, which resulted in esotropia upon returning to the primary position. The esotropic episodes spontaneously resolved after approximately 2 min. These spells affected both medial rectus muscles. Both pupils remained normal throughout the examination. Magnetic resonance imaging revealed neither brain parenchyma/brain stem lesions nor tumor recurrence. Her symptoms were successfully treated with carbamazepine.ConclusionsEpisodic esotropia in the adducting eye following prolonged horizontal eccentric gaze is a significant characteristic of ONM affecting the bilateral medial rectus muscles (i.e., bilateral oculomotor ONM). In spite of its extreme rarity, ONM should be considered as a differential diagnosis of episodic diplopia, especially in patients with a history of radiotherapy around the parasellar area. Careful examination with prolonged eccentric gaze should be performed to achieve a correct diagnosis and avoid an extensive unnecessary workup.

Factors Associated With Inadequate Intraoperative Baseline Lower Extremity Somatosensory Evoked Potentials.

Intraoperative neurophysiologic monitoring involves the use of various modalities, including somatosensory evoked potentials (SEP), to assess the integrity of the at-risk nervous system during surgeries. Reliable baseline tracings are important because they are data against which future tracings are compared to detect potential injury. In some cases, adequate baselines may be difficult to achieve. Therefore, we analyzed several patient-specific factors to determine which variables are associated with inadequate intraoperative SEP baseline signals. This is a single-center, retrospective chart review of 631 consecutive patients who underwent spine or cranial surgeries between 2010 and 2011. Variables analyzed included age, glucose levels, diabetes mellitus type 2, hypertension, hyperlipidemia, height, weight, sex, smoking, preexisting neurologic conditions, surgical history, lower extremity edema, and neurologic examination findings. Association between these patient factors and baseline lower extremity SEP signals were analyzed. Height, weight, neurologic deficits, lower extremity edema, and history of neurologic disease are each associated with inadequate baseline lower extremity SEPs after controlling for confounding variables. Baseline signals were able to be acquired in 94.1% of patients. Adequate baselines are paramount for successful intraoperative neurophysiologic monitoring. However, certain patient-specific factors are associated with inadequate baseline SEP signals. Physical examination findings and a detailed chart review can be done to identify these factors and guide expectations during monitoring. Further research related to patient-specific factors amenable to modification can further improve our capacity to protect the nervous system during surgery.

Case 3: Early Severe Jaundice in a Term Infant

An appropriate-for–gestational age (AGA) African American female infant is born at term via elective, repeat cesarean section at 39 weeks’ gestation to a gravida 2, para 2 woman. The mother’s pregnancy had been complicated only by gestational hypertension, and maternal antenatal testing results were unremarkable. Maternal blood type is O positive with a negative antibody screen during pregnancy. Meconium fluid is noted at delivery; however, the infant is vigorous with a strong cry and requires only routine resuscitation with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. After resuscitation, the infant makes a transition to routine couplet care with an anticipated 48-hour stay. A cord blood sample is sent for blood type and direct antiglobulin test (DAT) per hospital protocol secondary to infant blood type finding of B-negative type with a negative DAT result. Her first 24 hours are uneventful with direct breastfeeding every 2 to 3 hours, 2 documented voids, 3 stools, and minimal weight loss. All documented vital signs and examination results are normal for a term newborn. At 24 hours after birth, a transcutaneous bilirubin test is attempted per standard newborn care plan, with the resulting value too high to detect. Serum total and direct bilirubin concentrations are found to be 21.7 mg/dL (360 μmol/L) and 0.6 mg/dL (10 μmol/L), respectively. The infant is transported directly to the NICU for continued management and preparation for possible exchange transfusion. With any case of hyperbilirubinemia, especially with early-onset or rapidly increasing levels, it is important to keep a broad differential to avoid missing benign versus more severe causes of jaundice. Categorizing by time of onset into 3 categories can be useful in establishing a differential diagnosis. These categories are based on newborn age: less than 24 hours after birth, between 24 and 72 hours after …

Friday, September 28, 2018 10:30 AM–12:00 PM abstracts: innovation, surface technology and biomechanics: 183. Correlation of intervertebral disc TNFα concentration with clinical characteristics of patients with acute and chronic inflammatory radiculopathy secondary to lumbar disc herniation

BACKGROUND CONTEXT The exact etiology of spinal nerve root injury associated with sciatica secondary to herniated nucleus pulposus (S/HNP) remains uncertain. The mechanism of injury is thought to be mediated in part, through an acute inflammatory response that involves the up-regulation of specific inflammatory cytokines. TNFα has been implicated as a key component of an inflammatory cascade that results in a painful “chemical radiculitis”. However, a randomized clinical trial has demonstrated that the IV administration of a TNFα inhibitor to patients with acute S/HNP has no added value when compared to saline infusion. A prospective cohort study has reported inconsistent therapeutic value to TNFα inhibition in patients with chronic S/HNP. PURPOSE To correlate HNP TNFα concentration with clinical characteristics of patients with acute and chronic S/HNP treated surgically. STUDY DESIGN/SETTING Prospective clinical assessment of patients with acute and chronic S/HNP. Enzyme linked immunosorbent assay (ELISA) of serum and disc tissue inflammatory cytokine content. PATIENT SAMPLE Inclusion: S/HNP of less than 1 year duration undergoing surgery; McCulloch score of 5/5 spinal nerve root motor score of >3/5; Exclusion: red flag condition, prior lumbar surgery, other active inflammatory disease. OUTCOME MEASURES Duration of sciatica symptoms at time of surgery. VAS and mRDQ scores within two weeks of time of surgery. TNFα concentration in extruded disc material measured by (ELISA) immunoassay. METHODS After obtaining informed consent, eligible patients with S/HNP undergoing laminectomy or discectomy surgery were enrolled. Clinical history including of date of onset of sciatica and spinal-nerve root neurological examination findings were recorded. Herniated disc tissue removed at the time of surgery was immediately placed in buffered solution containing protease inhibitors and was frozen or stored at −80°C. Disc tissue homogenates were analyzed in duplicate using ELISA (BioRad). Research ethics approval was obtained. RESULTS A total of 24 patients with sciatica secondary to HNP undergoing lumbar discectomy surgery were included in this study. The duration of sciatica symptoms ranged from 3 to 12 months. Herniated disc tissue TNFα concentrations ranged from 0.9 to 24pg/ml. TNFα concentration was highest in patients with acute sciatica CONCLUSIONS In this study population, the concentration of TNFα in herniated disc tissue diminished dramatically after 12 weeks duration of sciatica symptoms, but was not associated with VAS or mRDQ scores. TNFα concentrations were consistently low in patients with chronic sciatica. High disc tissue TNFα concentration was found in the majority of patients with clinical signs of severe nerve root irritation. These findings provide biochemical evidence that the etiology of both acute and chronic lumbosacral radiculopathy secondary to herniated nucleus pulposus is multifactorial and does not directly correlate to extruded disc material TNFα concentration. Treatment strategies based upon TNFα inhibition are likely to have limited therapeutic benefit beyond 12 weeks post onset of sciatica.

Excisão cirúrgica de um osteocondroma de raiz nervosa da cauda equina de cão

Background: Spinal neoplasms are classified into extradural, intradural/extramedullary or intramedullary. Intradural/extramedullary tumors include meningiomas and nerve sheath tumors, which arise from meninges or peripheral nerves around the spinal cord. Clinical signs are related to dysfunction of the involved nerve and include pain, nerve root signature and atrophy. Osteochondromas are benign tumors located within the bone, on its surface or in extra-osseous regions, when they are classified as soft tissue osteochondoma. The aim of this study is to describe a case of an osteochondroma in a nervous root of the cauda equina in a dog, whose surgical resection allowed the resolution of the clinical signs.Case: A 12-year-old, male, Labrador Retriever dog, was presented with a 40-day history of progressive, painful, pelvic limb paresis, with no improvement when treated with analgesics and acupuncture. Neurological abnormalities included paraparesis, sometimes worse in the left pelvic limb, that was carried flexed at the level of the stifle, hindlimb atrophy, decreased interdigital reflexes and pain in the lumbar spinal region, mainly over L6 vertebra. Results of blood count and serum biochemical analysis were unremarkable. Computed tomography (CT) of the lumbosacral area was performed and the evaluation of images in transverse and reconstructed dorsal and sagittal planes allowed the visualization of a hyperattenuating and calcified round structure with 8 mm x 6 mm, in the left side of vertebral canal, at the level of caudal epiphysis of L6. Lumbosacral (L7-S1) CT abnormalities, as subchondral sclerosis, mild disc margin bulging, spondylosis deformans and foraminal proliferation were also observed but were considered clinically insignificant. Then, a dorsal L6 laminectomy was performed and after opening of the vertebral canal it was observed the presence of an ovoid mass, in the left side of the medullary cone, measuring approximately 0.9 cm in length, originating from a sacral nerve root. This structure was excised and submitted to histopathological evaluation. The dog improved after surgery without any complications, and neurological functions were gradually recovered. The histopathology of the mass was confirmed as an osteochondroma.Discussion: The history and neurologic examination findings as well the improvement after surgery were compatible with the lesion visualized by TC in L6, rather than the degenerative changes in L7-S1. Regarding the position of the mass, the main differential would be nerve sheath tumor, one of the most common types of primary neoplasia of the peripheral nervous system, however in a CT study in dogs with brachial plexus and nerve roots neoplasms, calcification of the tumor was not observed. Most of benign cartilaginous tumors of soft tissue are chondromas/osteochondromas, and this lesion should not be confused with multiple osteochondroma or multiple cartilaginous exostoses, which have been reported as multifocal, proliferative lesions involving the surface of ribs, vertebrae and pelvis of young dogs. If this lesion is unique, it is called osteochondroma. There are two reports of chondromas into the first lumbar vertebrae of dogs, with adherence to the floor of the vertebral canal and one report of an osteochondroma originated from the left pedicle of T11 in a cat. Radiculopathy and myelopathy caused by osteochondromas inside the spine are rare in humans and description of this tumor arising from nerve roots were not found in the veterinary literature. Probably the origin of the mass was metaplasia of the meninges surrounding the nervous root. In conclusion, neurological examination, CT and surgical exploration allowed the diagnosis and removal of a soft tissue osteochondroma, a rare benign tumor, with good patient recovery.

Emergency Department Use of Neuroimaging in Children and Adolescents Presenting with Headache

To evaluate emergency department use and outcomes of neuroimaging for headache in a free-standing children's hospital system. We prospectively enrolled children aged 6-18 years who presented to the emergency department with a chief complaint of headache from September 2015 to September 2016. Standardized data collection was performed in real time, including telephone follow-up as needed, and imaging outcome was determined through a chart review. Using multivariable logistic regression, we estimated the associations between clinically important patient characteristics and neuroimaging. Of 294 enrolled patients, 53 (18%) underwent neuroimaging (computed tomography or magnetic resonance imaging) and 2 (0.7%) had clinically important intracranial findings. Presenting with abnormal neurologic examination findings (OR, 11.55; 95% CI, 3.24-41.22), no history of similar headaches (OR, 2.13; 95% CI, 1.08-4.18), and white race (OR, 3.04; 95% CI, 1.51-6.12) were significantly associated with an increased odds of undergoing imaging in multivariable regression models. Our observed emergency department imaging rate was 26.5 times higher than our positive result rate, suggesting there is room to decrease unnecessary neuroimaging. Associations for abnormal examination and new headache type are consistent with the American Academy of Neurology clinical imaging recommendations. The increased odds of imaging white patients suggests bias that should be addressed. The low rate of positive findings supports the need for an evidence-based clinical decision tool for neuroimaging in the acute care setting.

Re-emergence of thiamine deficiency disease in the Pacific islands (2014-15): A case-control study.

BackgroundFrom late 2014 multiple atolls in Kiribati reported an unusual and sometimes fatal illness. We conducted an investigation to identify the etiology of the outbreak on the most severely affected atoll, Kuria, and identified thiamine deficiency disease as the cause. Thiamine deficiency disease has not been reported in the Pacific islands for >5 decades. We present the epidemiological, clinical, and laboratory findings of the investigation.Methodology/Principal findingsWe initially conducted detailed interviews and examinations on previously identified cases to characterize the unknown illness and develop a case definition. Active and passive surveillance was then conducted to identify additional cases. A questionnaire to identify potential risk factors and blood samples to assay biochemical indices were collected from cases and asymptomatic controls. Thiamine hydrochloride treatment was implemented and the response to treatment was systematically monitored using a five-point visual analogue scale and by assessing resolution of previously abnormal neurological examination findings. Risk factors and biochemical results were assessed by univariate and multivariate analyses. 69 cases were identified on Kuria (7% attack rate) including 34 confirmed and 35 unconfirmed. Most were adults (median age 28 years [range 0–62]) and 83% were male. Seven adult males and two infants died (13% case fatality rate). Resolution of objective clinical signs (78%) or symptoms (94%) were identified within one week of starting treatment. Risk factors included having a friend with thiamine deficiency disease and drinking kava; drinking yeast alcohol reduced the risk of disease. Higher chromium (p<0·001) but not thiamine deficiency (p = 0·66) or other biochemical indices were associated with disease by univariate analyses. Chromium (p<0·001) and thiamine deficiency (p = 0·02) were associated with disease by multivariate analysis.Conclusions/SignificanceAn outbreak of thiamine deficiency disease (beriberi) in Kiribati signals the re-emergence of a classic nutritional disease in the Pacific islands after five decades. Although treatment is safe and effective, the underlying reason for the re-emergence remains unknown. Chromium was highly and positively correlated with disease in this study raising questions about the potential role of factors other than thiamine in the biochemistry and pathophysiology of clinical disease.

Diagnostic yield of neuroimaging in syncope patients without high-risk symptoms indicating neurological syncope

ObjectivesDiagnostic tests are widely used for patients with syncope in the emergency department (ED). This study aimed to determine the diagnostic yield of neuroimaging in patients with syncope without high-risk symptoms. MethodsAdult patients who presented to the ED with syncope in 2016 were screened retrospectively. Patients who suffered from mild head trauma due to syncope were also included. Patients with neurological examination findings (confusion, amnesia, focal neurological deficit, severe headache, dizziness, nausea and vomiting), patients on anticoagulants, patients with known intracranial malignancies and those whose loss of consciousness was attributed to reasons other than syncope were excluded from the study. ResultsA total of 1114 patients were included in the study. The median age was 48 years (IQR = 34–66 years) and 576 (51.7%) of the patients were male. The neuroimaging tests performed were cranial computerized tomography (CT) in 694 (62.3%) cases and magnetic resonance imaging (MRI) in 114 (10.2%) cases. Mild head trauma due to syncope was observed in 116 (10.4%) patients. None of the neuroimaging studies revealed any clinically significant findings. ConclusionNeuroimaging is not beneficial in patients whose medical history and physical examination do not indicate neurogenic syncope, even if the patient has mild head trauma.

Anti-N-methyl-D-aspartate receptor encephalitis relapse in the brainstem

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune disorder involving IgG antibody reaction against NMDAR. It typically develops in women with ovarian teratoma, and its characteristic clinical symptoms include acute behavioural...

Lumbar Disc Herniations Causing Contralateral Radicular Symptoms: Can They Be Explained by Hypotenusal Theory?

Cases presenting contralateral radicular symptoms are rarely encountered. It is difficult to decide on the correct side in cases where surgical intervention will be performed. The aim of the study is to explain the symptomatology in cases of lumbar disc herniations causing contralateral radicular symptoms by a hypotenusal effect. In total, 27 cases were included in the study. Eight cases underwent surgical interventions performed on the side where disc herniation was radiologically detected. Nineteen cases were treated conservatively. Disc herniations were radiologically evaluated in 3 different groups, and the effect on the root on the symptomatic side was explained by a hypotenusal theory. Correlations among symptomatology, clinical findings, magnetic resonance imaging, and electromyography were discussed. Clinical improvement was observed in all cases that were operated on the side where disc herniation was detected radiologically. Neurologic examination findings in the postoperative period also revealed the correctness of the selected surgical approach. Electromyography is insufficient to explain clinical findings and to decide on the surgical side. Lumbar disc herniations, which lead to contralateral radicular symptoms, should be operated from the side where the disc is radiologically detected. The top of the disc is responsible for symptomatology. Surgical excision of the top of the disc removes the contralateral root traction and root compression on the same side.

Computed tomography Scan Findings among Pediatric Patients with unprovoked Seizures: a Hospital-Based Study

Objective. To describe the radiologic findings in pediatric patients who underwent cranial CT scan for unprovoked seizures at the Philippine General Hospital (PGH) and determine whether there is any association between the demographic characteristics such as age, age at onset, gender, as well as normal or abnormal neurologic examination findings, and the abnormal CT scan findings.&#x0D; Methods. Official results of all pediatric patients who underwent cranial CT scan for unprovoked seizures from January 1, 2015 to December 31, 2015 in PGH were reviewed. Data were described and statistically analyzed for differences in CT scan findings between different sexes, age groups, ages at onset, and presence or absence of neurologic findings.&#x0D; Results and Conclusion. Of the 88 cases included, 29 (32.95%) had abnormal CT findings. The most common finding was volume loss. No statistically significant difference was noted for the frequency of abnormal CT findings between categories. There was a trend towards more frequent abnormal CT scan findings among males, and among patients exhibiting abnormal neurologic findings.

Evaluation of spinal involvement in children with mucopolysaccharidosis VI: the role of MRI

To evaluate spinal MRI features of mucopolysaccharidosis (MPS) VI and to assess the correlation with clinical findings. We retrospectively evaluated spinal MRI scans and clinical findings at the time of imaging in 14 patients (8 male, 6 female) with MPS VI. Craniometric measurements were performed and the images were assessed for bony anomalies, spinal stenosis and spinal cord compression. The degree of cervical cord compression was scored and correlated with neurological examination findings at the time of imaging. Vertebral alignment, structural changes in spinal ligaments and intervertebral discs were also assessed. All patients had cervical stenosis due to bony stenosis and thickened retrodental tissue (median: 6.05 mm, range 3.3-8 mm). Retrodental tissue thickness was found to increase with age (p = 0.042). Compressive myelopathy was detected at upper cervical level in 11 (79%) and lower thoracic level in 2 patients (14%). Significant inverse correlation was found between cervical myelopathy scores and neurological strength scores. The most common bony changes were hypo/dysplastic odontoid; cervical platyspondyly with anterior inferior beaking; thoracic posterior end plate depressions and lumbar posterior scalloping. Kyphosis due to retrolisthesis of the beaked lumbar vertebrae and acute sacrococcygeal angulations were other remarkable findings. MRI is an essential component in evaluation of spinal involvement in MPS VI, and scanning of the entire spine is recommended to rule out thoracic cord compression. Advances in knowledge: This study provides a detailed description of spinal MRI findings in MPS VI and underlines the role of MRI in management of cord compression.

Epidemiology of head injuries and helmet use among motorcycle crash injury: a quantitative analysis from a local hospital in Western Kenya.

IntroductionInjury from motorcycle is a considerable cause of deaths and disability in the world. It is becoming one of the most serious public health problems, not only in developed countries but more in low and middle-income countries.MethodsDescriptive cross sectional study for patients who sustained head injuries related to motorcycle crashes between March 2017 and March 2018. Participant bio data, injury history and neurological examination findings were collected using pretested interviewer administered questionnaires. Frequencies, Mean (SD) and chi-square was employed in the analysis. Results were considered significant at p<0.05.ResultsA total of 341 motorcycle crash injury patients participated in the study. One hundred and forty three (42%), sustained head injuries while 198 (58%) sustained other types of injury. In regard to safety helmets, 94 (28%) wore helmets at the time of crash. One hundred and forty three (42%), of the respondents without helmets at the time of crash sustained head injuries. Riders and passengers who wore helmets at the time of motorcycle crash, suffered less frequent head injuries compared to those who did not wear helmets and this was statistically significant (χ2=55.78, P<0.00). Non use of safety helmet during crash was associated with sustaining mild to severe head injury. Most of the crashes 165 (48.3%), occurred as a result of collision between motorcycles versus vehicle. Majority of the crashes occurred in the afternoon hours 174 (51%). The days of the week recording the highest number of injuries were Friday (16.1%) and Monday (15.8%). The day of Involvement in motorcycle crash during the week was not significantly associated with head injury (χ2=13.103, p=0.785).ConclusionMajority of motorcycle crash injury victims sustained head injury. Few of the victims used safety helmets at the time of the motorcycle crash. Use of helmets was protective of sustaining mild to severe head injuries among crash injury victims.

Infarkti mozga granične supratentorijalne lokalizacije i kardiovaskularni rizični faktori

Introduction: During the course and development of diverse cardiological diseases different central nervous system complications may develop. These are most frequently related to the nature of the cardiovascular entity itself. Aim: To evaluate the association between atherogenesis factors and border zones strokes within the cerebral medial artery vascularization territories. Methods: In total 30 patients were enrolled in the study. Stroke diagnosis was based according to clinical and neurological examination and brain CT findings. The study analyzed risk factors correspondingly to World Health Organization criteria. Results: In majority of patients (18; 60%) arterial hypertension was diagnosed. Additionally, following condition and risk factors were identified: cardiological diseases (17; 23.3%), cigarette smoking (13, 43.3%), hypercholeterolaemia (9; 30%) and diabetes (7; 23.3%). In the group with cardiological diseases most frequent was myocardial infarction (9; 56.2%), AV block II and III (5, 29.4%), atrial fibrillation with slow ventricular response (3; 17.6%). Conclusion: Results of the study point to conclusion that myocardial infarction, AV block II and III, atrial fibrillation with slow ventricular response, iatrogenic hypertension and traditional risk factors for atherogenesis significantly influences presentation of the border zone strokes within the cerebral medial artery vascularization territories.