Neurological Recovery In Patients Research Articles

Neurological Recovery after Posterior Spinal Surgery in Patients with Metastatic Epidural Spinal Cord Compression.

Metastatic epidural spinal cord compression (MESCC) is a common complication in patients with a malignant tumor, but it is difficult to decide the proper time to perform the necessary surgery. Here we analyzed the prognostic factors for postoperative walking ability. We retrospectively reviewed the cases of 112 MESCC patients treated surgically at our institute and divided them into ambulatory (n＝ 88) and non-ambulatory (n＝24) groups based on their American Spinal Injury Association (ASIA) Impairment Scale grades at the final follow-up. We also classified the patients preoperatively using the revised Tokuhashi score. We assessed the correlation between preoperative or intraoperative factors and postoperative walking ability in both groups. Of the 10 patients classified preoperatively as grade A or B, 2 (20% ) were ambulatory at the final follow-up. Of the 102 patients classified preoperatively as grade C, D or E, 86 (84% ) were ambulatory at the final follow-up (p＜0.001). There were no significant differences between the groups in the average total Tokuhashi score. Our analysis revealed that the severity of paralysis significantly affects neurological recovery in patients with MESCC. Patients with MESCC should receive surgery before the preoperative ASIA Impairment Scale grade falls below grade C.

Biomarkers in spinal cord compression Ethics and perspectives

Abstract The phosphorylated form of the high-molecular-weight neurofilament subunit NF-H (pNF-H) in serum or in cerebro-spinal fluid (CSF) is a specific lesional biomarker for spinal cord injury. The lesional biomarkers and the reaction biomarkers are both presented after several hours post-injury. The specific predictive patterns of lesional biomarkers could be used to aid clinicians with making a diagnosis and establishing a prognosis, and evaluating therapeutic interventions. Diagnosis, prognosis, and treatment guidance based on biomarker used as a predictive indicator can determine ethical difficulties by differentiated therapies in patients with spinal cord compression. At this point based on studies until today we cannot take a decision based on biomarker limiting the treatment of neurological recovery in patients with complete spinal cord injury because we do not know the complexity of the biological response to spinal cord compression.

A multicentre observational study of inter-hospital transfer for post-resuscitation care after out-of-hospital cardiac arrest

AimTo provide therapeutic hypothermia (TH) to survivors after out-of-hospital cardiac arrest (OHCA), inter-hospital transfers (IHT) are frequently required. The safety of IHT remains controversial. The aim of this study was to investigate whether the effect of TH on brain recovery after OHCA differs between IHT and direct arrival groups. MethodsWe identified patients with OHCA of presumed cardiac aetiology who were resuscitated by emergency medical services and experienced return-of-spontaneous circulation in 27 hospitals between January and December 2014. The main exposure variables were TH and IHT. The primary endpoint was discharge with good neurological recovery. We compared outcomes between the TH and non-TH groups using multivariable logistic regression with an interaction term between TH and IHT, after adjusting for potential confounders. ResultsAmong 1616 patients, 576 patients were included in the final analyses. Neurologic recovery was better in the TH group (46.2%) than in the non-TH group (20.1%) (adjusted odds ratio [aOR] 2.03 [95% confidence interval (CI) 1.24–3.33]). In the interaction model for the outcome of good neurological recovery, the aOR for TH was 2.82 (95% CI 1.59–5.01) in the direct transfer group vs. 0.76 (95% CI 0.29–2.01) in the IHT group. The measure of interaction on the multiplicative scale in this model was also statistically significant (OR 0.27 [95% CI 0.07–0.83]; p=0.02). ConclusionIHT modified the effect of TH on neurological recovery for survivors of OHCA. TH is significantly less beneficial for good neurological recovery in patients who arrive via IHT than for those who arrive directly.

Predicting Neurologic Recovery after Surgery in Patients with Deficits Secondary to MESCC

Systematic literature review and expert survey OBJECTIVE.: The aim of this study was to determine factors associated with neurologic improvement in patients with neurologic deficits secondary to metastatic epidural spinal cord compression (MESCC). Clear understanding of these factors will guide surgical decision-making by helping to elucidate which patients are more likely to benefit from surgery and how surgeons can increase the probability of neurologic and functional restoration. Surgical spinal cord decompression has been shown to improve neurologic function in patients with symptomatic MESCC. However, prognostication of neurologic improvement after surgery remains challenging, owing to sparse data and complexity of these patients. PubMed and Embase databases were searched for relevant publications. PRISMA Statement guided publication selection and data reporting. GRADE guidelines were used for evidence quality evaluation and recommendation formulation. Low-quality evidence supports the use of the duration and severity of neurologic deficit as predictors of neurological recovery in patients with MESCC. Low-quality evidence supports the use of thoracic level of compression and previous irradiation as adverse predictors of neurological recovery. Nearly all of the AOSpine Knowledge Forum Tumor members who responded to the survey agreed that ambulation with assistance represented a successful surgical result and that duration of ambulation loss and the severity of weakness should be considered when trying to predict whether surgery would result in restoration of ambulation. Review of literature and expert opinion support the importance of duration of ambulation loss and the severity of neurologic deficit (muscle strength, bladder function) in prediction of neurologic recovery among patients with symptomatic MESCC. Efforts to reduce the duration of ambulation loss and to prevent progression of neurologic deficits should be made to improve the probability of neurologic recovery. 2.

Is bispectral index (BIS) monitoring in the emergency department helpful for prognostication during resuscitation of cardiac arrest patients?

Objective: It has been suggested that bispectral index (BIS) can be indicative of cerebral perfusion during advanced cardiac life support (ACLS) resuscitation of cardiac arrest patients. Our aim was to determine whether BIS monitoring during resuscitation in the emergency department (ED) can predict survival or neurological outcomes of patients with cardiac arrest. Methods: This was a prospective, single-centre, observational cohort study in the ED of a tertiary hospital, where we included 100 patients whom received resuscitation in the ED between December 2010 and March 2014. We recorded BIS values, suppression ratio, electromyography and signal quality index; throughout the resuscitation. A research coordinator set up the monitoring apparatus at the earliest time possible. Results: Out of the 100 patients recruited, 22 had a sustained return of spontaneous circulation (ROSC) and were admitted to the intensive care unit (ICU). Of these, 19 patients subsequently died in the ICU, two were discharged with good neurological recovery (cerebral performance category (CPC) 1) and one was discharged with poor neurological recovery (CPC4). By comparing the groups of patients who died in the ICU and were discharged, we found there was no significant difference in the initial BIS score ( p = 0.64), the score upon ROSC ( p = 0.36), the average BIS score 10 minutes post-ROSC ( p = 0.35), nor the BIS score upon admission to the ICU ( p = 0.22). Conclusions: Very early monitoring of BIS before admission to the ICU predicts neither survival nor neurological recovery in patients with cardiac arrest. Very low BIS scores in the ED may not indicate a poor prognosis, especially in patients undergoing therapeutic hypothermia.

Automated assessment of early hypoxic brain edema in non-enhanced CT predicts outcome in patients after cardiac arrest

IntroductionEarly prediction of potential neurological recovery in patients after cardiac arrest is challenging. Recent studies suggest that the densitrometic gray-white matter ratio (GWR) determined from cranial computed tomography (CT) scans may be a reliable predictor of poor outcome. We evaluated an automated, rater independent method to determine GWR in CT as an early objective imaging predictor of clinical outcome. MethodsWe analyzed imaging data of 84 patients after cardiac arrest that underwent noncontrast CT within 24h after arrest. To determine GWR in CT we applied two methods using a recently published automated probabilistic gray-white matter segmentation algorithm (GWR_aut) and conventional manual measurements within gray-white regions of interest (GWR_man). Neurological outcome was graded by the cerebral performance category (CPC). As part of standard routine CPC was assessed by the treating physician in the intensive care unit at admission and at discharge to normal ward. The performance of GWR measures (automated and manual) to predict the binary clinical endpoints of poor (CPC3–5) and good outcome (CPC1–2) was assessed by ROC analysis with increasing discrimination thresholds. Results of GWR_aut were compared to GWR_man of two raters. ResultsOf 84 patients, 55 (65%) showed a poor outcome. ROC curve analysis revealed reliable outcome prediction of GWR_aut (AUC 0.860) and GWR_man (AUC 0.707 and 0.699, respectively). Predictive power of GWR_aut was higher than GWR_man by each rater (p=0.019 and p=0.021, respectively) at an optimal cut-off of 1.084 to predict poor outcome (optimal criterion with 92.7% sensitivity, 72.4% specificity). Interrater reliability of GWR_man by intra-class correlation coefficient (ICC) was moderate (0.551). ConclusionAutomated quantification of GWR in CT may be used as an objective observer-independent imaging marker for outcome in patients after cardiac arrest.

Automated assessment of early hypoxic brain edema in non-enhanced CT predicts outcome in patients after cardiac arrest

Abstract Introduction Early prediction of potential neurological recovery in patients after cardiac arrest is challenging. Recent studies suggest that the densitrometic gray-white matter ratio (GWR) determined from cranial computed tomography (CT) scans may be a reliable predictor of poor outcome. We evaluated an automated, rater independent method to determine GWR in CT as an early objective imaging predictor of clinical outcome. Methods We analyzed imaging data of 84 patients after cardiac arrest that underwent noncontrast CT within 24h after arrest. To determine GWR in CT we applied two methods using a recently published automated probabilistic gray-white matter segmentation algorithm (GWR_aut) and conventional manual measurements within gray-white regions of interest (GWR_man). Neurological outcome was graded by the cerebral performance category (CPC). As part of standard routine CPC was assessed by the treating physician in the intensive care unit at admission and at discharge to normal ward. The performance of GWR measures (automated and manual) to predict the binary clinical endpoints of poor (CPC3–5) and good outcome (CPC1–2) was assessed by ROC analysis with increasing discrimination thresholds. Results of GWR_aut were compared to GWR_man of two raters. Results Of 84 patients, 55 (65%) showed a poor outcome. ROC curve analysis revealed reliable outcome prediction of GWR_aut (AUC 0.860) and GWR_man (AUC 0.707 and 0.699, respectively). Predictive power of GWR_aut was higher than GWR_man by each rater ( p =0.019 and p =0.021, respectively) at an optimal cut-off of 1.084 to predict poor outcome (optimal criterion with 92.7% sensitivity, 72.4% specificity). Interrater reliability of GWR_man by intra-class correlation coefficient (ICC) was moderate (0.551). Conclusion Automated quantification of GWR in CT may be used as an objective observer-independent imaging marker for outcome in patients after cardiac arrest.

The effect of increased T2 signal intensity in the spinal cord on the injury severity and early neurological recovery in patients with central cord syndrome

OBJECTIVE The aim of this paper was to compare the severity of the initial neurological injury as well as the early changes in the American Spinal Injury Association (ASIA) motor score (AMS) between central cord syndrome (CCS) patients with and without an increased T2 signal intensity in their spinal cord. METHODS Patients with CCS were identified and stratified based on the presence of increased T2 signal intensity in their spinal cord. The severity of the initial neurological injury and the progression of the neurological injury over the 1st week were measured according to the patient's AMS. The effect of age, sex, congenital stenosis, surgery within 24 hours, and surgery in the initial hospitalization on the change in AMS was determined using an analysis of variance. RESULTS Patients with increased signal intensity had a more severe initial neurological injury (AMS 57.6 vs 75.3, respectively, p = 0.01). However, the change in AMS over the 1st week was less severe in patients with an increase in T2 signal intensity (-0.85 vs -4.3, p = 0.07). Analysis of variance did not find that age, sex, Injury Severity Score, congenital stenosis, surgery within 24 hours, or surgery during the initial hospitalization affected the change in AMS. CONCLUSIONS The neurological injury is different between patients with and without an increased T2 signal intensity. Patients with an increased T2 signal intensity are likely to have a more severe initial neurological deficit but will have relatively minimal early neurological deterioration. Comparatively, patients without an increase in the T2 signal intensity will likely have a less severe initial injury but can expect to have a slight decline in neurological function in the 1st week.

Impact on Neurological Recovery of Transforaminal Debridement and Interbody Fusion versus Transpedicular Decompression in Combination with Pedicle Screw Instrumentation for Treating Thoracic and Lumbar Spinal Tuberculosis.

Study DesignRetrospective study.PurposeTo compare the neurological outcome of transforaminal debridement and interbody fusion with transpedicular decompression for treatment of thoracic and lumbar spinal tuberculosis.Overview of LiteratureFew articles have addressed the impact of neurological recovery in patients with tuberculosis who were treated by two different operative methods via the posterior-only approach.MethodsClinical and radiographic results of one-stage posterior instrumented spinal fusion for treatment of tuberculous spondylodiscitis with neurological deficits were reviewed and analyzed from 2009 to 2013. The extensive (E) group consisted of patients who received transforaminal debridement and interbody fusion, whereas transpedicular decompression was performed on limited (L) group. Rapid recovery was improvement of at least one Frankel grade within 6 weeks after operation. Otherwise, it was slow recovery.ResultsAll 39 patients had improved neurological signs. The median follow-up period was 24 months. Proportionately younger patients (under 65 years of age) received extensive surgery (15 of 18, 83.3% vs. 11 of 21, 52.4%; p=0.04). The mean operative time and blood loss in the group E were higher than in the group L (both p<0.01). With regard to type of procedure, especially at thoracic and thoracolumbar spine, patients who underwent extensive surgery had rapid neurological recovery significantly different from those of limited surgery (p=0.01; Relative Risk, 3.06; 95% Confidence Interval, 1.13 to 8.29).ConclusionsTransforaminal debridement and interbody fusion provides more rapid neurological recovery in patients with thoracic and thoracolumbar spinal tuberculosis compared to transpedicular decompression.

Mild therapeutic hypothermia in patients resuscitated from out-of-hospital cardiac arrest: A meta-analysis of randomized controlled trials.

Aims:Guidelines recommend mild therapeutic hypothermia (MTH) for survivors of out-of-hospital cardiac arrest (OHCA). However, there is little literature demonstrating a survival benefit. We performed a meta-analysis of randomized controlled trials (RCTs) assessing the efficacy of MTH in patients successfully resuscitated from OHCA.Materials and Methods:Electronic databases were searched for RCT involving MTH in survivors of OHCA, and the results were put through a meta-analysis. The primary endpoint was all-cause mortality, and the secondary endpoint was favorable neurological function. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using the Mantel–Haenszel method. A fixed-effect model was used and, if heterogeneity (I2) was >40, effects were analyzed using a random model.Results:Six RCT (n = 1400 patients) were included. Overall survival was 50.7%, and favorable neurological recovery was 45.5%. Pooled data demonstrated no significant all-cause mortality (OR, 0.81; 95% CI 0.55–1.21) or neurological recovery (OR, 0.77; 95% CI 0.47–1.24). No evidence of publication bias was observed.Conclusion:This meta-analysis demonstrated that MTH did not confer benefit on overall survival rate and neurological recovery in patients resuscitated from OHCA.

Correlation of Glasgow outcome score to Glasgow coma score assessed at admission

Background: Traumatic brain injury is one of the leading causes for morbidity and mortality in trauma cases. GCS is the standard scoring system used globally to assess the neurological status of patients with traumatic brain injury. The GOS is used to objectively assess and categorize patients recovering from head injury. In this study we assessed the GOS of patients recovering from traumatic brain injury and analysed its correlation with the initial GCS thereby evaluating the use of GCS in predicting recovery of patients with head injury. Methods: 82 patients with isolated traumatic brain injury were included in the study. GCS was recorded at admission, 6 hours and 12 hours. GOS was recorded at 7 days and 28 days. Statistical analysis was done using Pearson’s Correlation co-efficient. Results: There was statistically significant positive correlation between GCS recorded on admission with GOS recorded on day 7 and GOS recorded on day 28. Positive Correlation was also seen between GCS recorded at 6 hours with GOS recorded on day 7 and GOS recorded on day 28. Similar positive correlation was also seen between GCS recorded at 12 hours with GOS recorded on day 7 and GOS recorded on day 28. Conclusions: GCS can be used as a tool to stratify risk, prognosis and neurological recovery in patients with traumatic brain injury. It has to be used with caution in patients with polytrauma as other serious injuries may increase the risk, morbidity and mortality.

Saving life and brain with extracorporeal cardiopulmonary resuscitation: A single-center analysis of in-hospital cardiac arrests

ObjectiveDespite advances in medical care, survival to discharge and full neurologic recovery after cardiac arrest remains less than 20% after cardiopulmonary resuscitation. An alternate approach to traditional cardiopulmonary resuscitation is extracorporeal cardiopulmonary resuscitation, which places patients on extracorporeal membrane oxygenation during cardiopulmonary resuscitation and provides immediate cardiopulmonary support when traditional resuscitation has been unsuccessful. We report the results from extracorporeal cardiopulmonary resuscitation at the Thomas Jefferson University. MethodsBetween 2010 and June 2014, 107 adult extracorporeal membrane oxygenation procedures were performed at the Thomas Jefferson University. Patient demographics, survival to discharge, and neurologic recovery of patients who underwent extracorporeal cardiopulmonary resuscitation were retrospectively analyzed with institutional review board approval. ResultsA total of 23 patients (15 male and 8 female; mean age, 46 ± 12 years) underwent extracorporeal cardiopulmonary resuscitation. All patients who met criteria were placed on 24-hour hypothermia protocol (target temperature 33°C) with initiation of extracorporeal membrane oxygenation. The mean duration of extracorporeal membrane oxygenation support was 6.2 ± 5.5 days. Nine patients died while on extracorporeal membrane oxygenation from the following causes: anoxic brain injury (4), stroke (4), and bowel necrosis (1). Two patients with anoxic brain injury on extracorporeal cardiopulmonary resuscitation donated multiple organs for transplant. The survival to discharge was 30% (7/23 patients) with approximately 100% full neurologic recovery. ConclusionsThe extracorporeal cardiopulmonary resuscitation procedure provided reasonable patient recovery. Extracorporeal cardiopulmonary resuscitation also allowed for neurologic recovery and made multiorgan procurement possible. On the basis of the survival, extracorporeal cardiopulmonary resuscitation should be considered when determining the optimal treatment path for patients who need cardiopulmonary resuscitation. The proper use of extracorporeal cardiopulmonary resuscitation improved the hospital outcomes for patients with in-hospital cardiac arrest.

Magnetic Resonance Imaging association with the preoperative Neurological Status and its Predictive Value of the Postoperative Recovery in Patients with Cervical Spondylotic Myelopathy

Introduction This is a prospective observational study of consecutive patients undergoing surgery with cervical spondylotic myelopathy (CSM), to assess the association of the quantitative assessment of preoperative magnetic resonance imaging (MRI) with the preoperative neurological status and postoperative neurological recovery. The factors of predictive value to the neurological recovery in patients with CSM postoperatively are of great interest. Currently, the significance of MRI signal changes in relation to prognosis in the literature is conflicting and inconsistent. Patients and Methods A 50 consecutive patients with CSM were studied preoperatively and postoperatively after 1 year. Modified Japanese Orthopedic Association (mJOA) was recorded preoperatively and 1 year after surgery. Using univariate and multivariate analysis, the relation of the preoperative status and postoperative recovery to quantitative MRI measurements preoperatively were assessed. Results Low T1 signal change preoperatively was associated with a lower preoperative mJOA ( p = 0.021). Focal high T2 signal was associated with lower preoperative mJOA scores ( p = 0.62). Preoperative focal T2 signal had a significant association with poorer postoperative recovery rate ( p = 0.032). Conclusion MRI signal changes can predict preoperative neurological status and postoperative recovery. The presence of hypointense T1 signal and focal hyperintense T2 signal on MRI are indicators of poorer outcome.

The effect of preexisting hypertension on early neurologic results of patients with an acute spinal cord injury.

Retrospective case-control. To characterize changes in American Spinal Injury Association Motor Score (AMS) in patients treated with relative hypertension (HTN) (mean arterial pressure (MAP) > 85 mm Hg for 5 days) with and without preexisting HTN. A regional spinal cord injury (SCI) center in Pennsylvania, United States. All patients with an acute SCI who were treated with induced HTN (MAP goal above 85) in the intensive care unit (ICU) for at least 5 days were identified. Patients were stratified based on the presence of preexisting HTN, and the change in the AMS between admission and day 5 was determined. Predictors of outcome were identified using correlation analysis and multiple linear regression. Ninety-two patients met inclusion criteria of which 22 had a previous history of HTN. HTN was a predictor of poor early outcome. Patients with HTN had an average decline in their AMS of 7.6, compared with an average decrease of only 0.6 in the AMS of patients without HTN (P=0.04). HTN had no effect (P>0.05) on other in-hospital variables including length of stay, length of stay in the ICU, complications or mortality. Additionally, multiple linear regression analysis demonstrated that diabetes, coronary artery disease and pulmonary disease had no effect on the change in AMS. Chronic HTN is an independent risk factor for poor early neurologic recovery in patients treated with relative HTN for an acute SCI. This is independent of age and other comorbidities.

The effect of vertebral fracture on the early neurologic recovery in patients with central cord syndrome.

To compare early changes in the ASIA Motor Score (AMS) between patients with central cord syndrome (CCS) from an acute fracture to patients without a fracture. Patients with CCS were identified and stratified based on the presence of a fracture. The AMS through the first week of the patients' hospitalization was obtained. Initial injury severity as well as early neurologic recovery was measured using the AMS. Analysis of variance was performed to determine if age, gender, rectal tone at presentation, congenital stenosis, or surgery within 24h significantly effected the change in AMS. A strong trend (p=0.0504) towards a more severe initial neurologic injury in patients with a fracture (AMS 59.7) than in patients without a fracture (AMS 70.2) was identified. However, in the week after injury, patients with a fracture had an improvement in their neurologic function (ΔAMS +4.8) while patients without a fracture demonstrated neurologic decline (ΔAMS -5.9). The change in AMS between patients with and without a fracture was nearly significant (p=0.06). Patients with central cord syndrome present with similar symptoms, but injuries with and without a fracture may be associated with a different early neurologic recovery. Patients with a fracture have a more severe injury at initial presentation, but tend to have neurologic improvement in the first week; conversely patients without a fracture have a less severe initial neurologic injury, but tend to have a slight decline in neurologic function over the first week.

Interaction effects between hypothermia and diabetes mellitus on survival outcomes after out-of-hospital cardiac arrest

ObjectivesMild therapeutic hypothermia (MTH) is the core hospital intervention to enhance neurological outcome after out-of-hospital cardiac arrest (OHCA). Diabetes mellitus (DM) has been known to be a harmful risk factor on survival after OHCA. This study aimed to investigate whether the effect of MTH on brain recovery after OHCA differed between patients with or without DM. MethodsWe used a Korean national OHCA database composed of hospital and ambulance data. We included adult OHCA patients who survived to admission with presumed cardiac etiology during the study period from 2009 to 2013. We excluded cases without hospital outcome data. The primary exposure was MTH, which included all kinds of cooling methods that had been initiated within 6h after return of spontaneous circulation. DM was coded positive when the patient had a clinical history diagnosed by a physician before an OHCA event. The endpoints were discharge with good neurological recovery (cerebral performance category 1 or 2) and survival to discharge. We compared outcomes between MTH vs. non-MTH groups using multivariable logistic regression with an interaction term between MTH and DM for calculating adjusted odds ratios (AORs) and 95% confidence intervals (CIs) after adjusting for potential confounders. ResultsAmong 9735 patients following OHCA survived to hospital admission with cardiac etiology, MTH was performed in 16.5%. History of DM was observed in 25.4% among MTH group and 27.4% in non-MTH group (p=0.09). MTH group showed better outcomes than non-MTH group; 23.6% vs. 15.7% for good neurological recovery (p<0.01). AOR (95% CI) of MTH for good neurological recovery for all study groups was 1.23 (1.03–1.47). In the interaction model, AOR (95% CI) of MTH for good neurological recovery was 1.40 (1.16–1.70) in patients without DM vs. 0.69 (0.46–1.04) in patients with DM. For survival to discharge, the effects of MTH were different in patients without DM (1.97 (1.70–2.29)) and patients with DM (1.23 (0.96–1.57)). ConclusionDM modified the effect of MTH on survival and neurological outcomes for OHCA survivors. MTH is significantly associated with good neurological recovery in patients without DM, but not in patients with DM.

Clinical Characteristics and Neurologic Recovery of Patients with Cervical Spinal Tuberculosis: Should Conservative Treatment Be Preferred? A Retrospective Follow-Up Study of 115 Cases

To present the clinical characteristics and prognostic factors of neurologic recovery in patients with cervical spinal tuberculosis (CST). General description and multivariate analysis were used to detect possible predictors of the outcome of patients with neurologic deficit. Follow-up data were used to generate a Kaplan-Meier curve of neurologic recovery. Protective factors in neurologic recovery included less involved vertebrae, surgery, and higher Japanese Orthopaedic Association score before treatment; not shorter symptom duration was not a protective factor. Normal neurologic function was present in 30% of patients 6 months after treatment, in 56% of patients 12 months after treatment, and in 93% of patients 28 months after treatment. The cumulative complete neurologic recovery rates at 6 months, 12 months, and 28 months were 44%, 68%, and 91.7% in the surgery group and 16.7%, 38.8%, and 94.4% in the nonsurgery group. Surgery and Japanese Orthopaedic Association score before treatment are important predictors ofneurologic recovery in patients with CST. A neurologic recovery curve could predict neurologic recovery in patients with CST and indicate in patients with neurologic deficit how long it will take to achieve complete neurologic recovery. The effect of surgery is quick, and the effect of conservative treatment is slower, but no difference in neurologic recovery was found in the long-term. Conservative treatment should be tried in every patient with CST with no obvious indication for surgery. In contrast to patients with tuberculosis without cervical spine involvement but with more complications, comprehensive conservative therapy should be preferred for patients with neurologic deficit toavoid unnecessary surgery and overtreatment and to conserve medical resources. Indications for surgical intervention for CST should be carefully selected.

Evaluation of Traumatic Spine by Magnetic Resonance Imaging and Correlation with Neurological Recovery.

Study DesignProspective study.PurposeTo compare magnetic resonance imaging (MRI) findings with clinical profile and neurological status of the patient and to correlate the MRI findings with neurological recovery of the patients and predict the outcome.Overview of LiteraturePrevious studies have reported poor neurological recovery in patients with cord hemorrhage, as compared to cord edema in spine injury patients. High canal compromise, cord compression along with higher extent of cord injury also carries poor prognostic value.MethodsNeurological status of patients was assessed at the time of admission and discharge in as accordance with the American Spine Injury Association (ASIA) impairment scale. Mean stay in hospital was 14.11±5.74 days. Neurological status at admission and neurological recovery at discharge was compared with various qualitative cord findings and quantitative parameters on MRI. In 27 patients, long-term follow-up was done at mean time of 285.9±43.94 days comparing same parameters.ResultsCord edema and normal cord was associated with favorable neurological outcome. Cord contusion showed lesser neurological recovery, as compared to cord edema. Cord hemorrhage was associated with worst neurological status at admission and poor neurological recovery. Mean canal compromise (MCC), mean spinal cord compression (MSCC) and lesion length values were higher in patients presenting with ASIA A impairment scale injury and showed decreasing trends towards ASIA E impairment scale injury. Patients showing neurological recovery had lower mean MCC, MSCC, and lesion length, as compared to patients showing no neurological recovery (p<0.05).ConclusionsCord hemorrhage, higher MCC, MSCC, and lesion length values have poor prognostic value in spine injury patients.

Impact of time to cooling initiation and time to target temperature in patients treated with hypothermia after cardiac arrest.

Little is known about the role of time to initiation of therapeutic hypothermia and time to target temperature (TTT) in the prognosis of patients resuscitated from cardiac arrest. A retrospective analysis was performed in 145 survivors of cardiac arrest who underwent therapeutic hypothermia between January 2003 and January 2013. The objective was to identify predictors of survival free from significant neurological sequelae (Cerebral Performance Categories Scale (CPC): >2) six months after cardiac arrest. We evaluated the effect of faster and earlier cooling. Overall survival at six months was 42.1% (61 patients); 59 of these were considered to have a good neurological status (CPC ≤ 2), and in whom therapeutic hypothermia was initiated earlier (87 ± 17 min vs. 111 ± 14 min; p=0.042), and the target temperature was reached at an earlier time (TTT: 316 ± 30 min vs. 365 ± 27 min; p=0.017). Multivariate analysis selected longer duration of cardiac arrest (odds ratio (OR) = 1.06 per min), a non-shockable initial rhythm (OR=13.8), severe acidosis (OR=0.009 per 0.01 unit), older age (OR=1.04 per year) and longer TTT (OR=1.005 per min) as associated with poor prognosis. The most important prognostic factors for death or lack of neurological recovery in patients with cardiac arrest treated with therapeutic hypothermia are initial-rhythm, time from cardiac arrest to return of spontaneous circulation and arterial-pH at admission. Although the speed of cooling initiation and the time to reach target temperature may play a role, its influence on prognosis seems to be less important.

Early neuroprotection after cardiac arrest

Many efforts have been made in the last decades to improve outcome in patients who are successfully resuscitated from sudden cardiac arrest. Despite some advances, postanoxic encephalopathy remains the most common cause of death among those patients and several investigations have focused on early neuroprotection in this setting. Therapeutic hypothermia is the only strategy able to provide effective neuroprotection in clinical practice. Experimental studies showed that therapeutic hypothermia was even more effective when it was started immediately after the ischemic event. In human studies, the use of prehospital hypothermia was able to reduce the time to target temperature but did not result in higher survival rate or neurological recovery in patients with out-of-hospital cardiac arrest, when compared with standard in-hospital therapeutic hypothermia. Thus, intra-arrest hypothermia (i.e., initiated during cardiopulmonary resuscitation) may be a valid alternative to improve the effectiveness of therapeutic hypothermia in this setting; however, more clinical data are needed to demonstrate any potential benefit of such intervention on neurological outcome. Together with cooling, early hemodynamic optimization should be considered to improve cerebral perfusion in cardiac arrest patients and minimize any secondary brain injury. Nevertheless, only scarce data are available on the impact of early hemodynamic optimization on the development of organ dysfunction and neurological recovery in such patients. Some new protective strategies, including inhaled gases (i.e., xenon, argon, nitric oxide) and intravenous drugs (i.e., erythropoietin) are emerging in experimental studies as promising tools to improve neuroprotection, especially when combined with therapeutic hypothermia. Early cooling may contribute to enhance neuroprotection after cardiac arrest. Hemodynamic optimization is mandatory to avoid cerebral hypoperfusion in this setting. The combination of such interventions with other promising neuroprotective strategies should be evaluated in future large clinical studies.