Neurological Status Of Patients Research Articles

Screening for Diabetic Peripheral Neuropathy: Subjective Versus Objective Measures.

This study compared subjective screening modalities recommended in diabetic foot screening guidelines for the detection of diabetic peripheral neuropathy (DPN) with an objective measure, the NC-Stat DPNCheck®. We assessed 63 participants (mean age 54.5 years ± 10.5) utilising subjective screening tools (Semmes-Weinstein 10-g monofilament, 128-Hz traditional tuning fork, neurothesiometer, O'Brien 128-Hz electronic tuning fork) and compared results with the objective automated sural nerve conduction test NC-Stat DPNCheck®. A significant difference was found in the number of limbs classified with DPN between all screening tools (P < .05). Therefore, this suggests that some screening modalities are more sensitive in diagnosing DPN than others, highlighting the importance of using multiple screening tools to a comprehensive understanding of the patient's neurological status. The findings also emphasize the need to incorporate objective measures in diabetic foot screening and encourage future research to establish a gold standard tool for DPN diagnosis.

Association Between Neurological Status and Outcomes in Cardiac Arrest Patients Undergoing PCI in Contemporary Practice: Insights From BMC2.

Coronary artery disease remains the largest contributor to cardiac arrests worldwide; yet, long-term outcomes are often driven by neurological status after resuscitation. We examined the association between pre-percutaneous coronary intervention (PCI) level of consciousness (LOC) and outcomes among patients with cardiac arrest who underwent PCI. The study cohort included patients undergoing PCI after cardiac arrest between April 2018 and March 2022 at 48 hospitals in the state of Michigan. Pre-PCI LOC was categorized as mentally alert, partially responsive, unresponsive, and unable to assess. In-hospital outcomes included mortality, bleeding, and acute kidney injury. Among 3021 patients who underwent PCI after cardiac arrest, 1394 (49%) were mentally alert, 132 (5%) were partially responsive, 698 (24%) were unresponsive, and 631 (22%) were unable to assess. The mentally alert cohort had lower mortality (4.59%) compared with the partially responsive (17.42%), unresponsive (50.14%), and unable to assess cohorts (38.03%; P<0.001). After adjusting for baseline differences, compared with mentally alert patients, the odds of mortality were markedly elevated in patients who were partially responsive (adjusted odds ratio, 4.63 [95% CI, 2.67-8.04]; P<0.001), unable to assess (adjusted odds ratio, 13.95 [95% CI, 9.97-19.51]; P<0.001), and unresponsive (adjusted odds ratio, 24.36 [17.34-34.23]; P<0.001). After adjustment, patients with impaired LOC also had higher risks of acute kidney injury and bleeding compared with mentally alert patients. Pre-PCI LOC is a strong predictor of in-hospital outcomes after PCI among cardiac arrest patients. A patient's pre-PCI LOC should be considered an important factor when weighing treatment options, designing clinical trials, and counseling patients and their families regarding prognosis after PCI.

Metastatic Spinal Lesion with Minimal Epidural Compression: Surgical Treatment or Stereotactic Radiotherapy?

Introduction. The choice of treatment between extracranial stereotactic radiotherapy and surgery for metastatic vertebral body tumors with minimum or no epidural compression of the dura mater is yet to be clearly defined. Materials and methods. The study enrolled 41 patients who received treatment at the National Medical Research Centre for Oncology (Rostov-on-Don, Russia) from January 1, 2014 to December 31, 2022. The inclusion criterion was the presence of a metastatic vertebral tumor, with minimal or no epidural compression of the dura mater and the radicular infundibulum (ESCC 0–1b). Patients were divided into two groups: 21 patients (SBRT group) received only extracranial stereotactic radiation therapy and 20 patients who underwent surgery followed by adjuvant extracranial stereotactic radiation therapy 1 month after surgery (Op.+Аd.SBRT). Results. The early postoperative period revealed no deterioration in the neurological status of patients in the SBRT group, no improvement in the Karnofsky performance status and no regression of pain syndrome, in contrast to patients in the Op+Аd.SBRT group. In a month after the surgery, tumors continued to grow in 3 patients (21%) of the SBRT group and only in 1 patient (6%) of the Oр.+Аd.SBRT group. Discussion. In the early postoperative period, the Op.+Аd.SBRT group showed an improvement in the functional status and a significantly more pronounced regression of the pain syndrome in the patients of the SBRT group, which can be explained by direct decompression of the compressed spinal root and elimination of increasing instability of the spinal column. Conclusion. Surgical treatment complemented by adjuvant extracranial stereotactic radiation therapy constitutes the preferred treatment for patients with metastatic spinal lesion with minimal epidural spread, without epidural compression of the spinal cord, with severe pain syndrome and signs of increasing instability of the spinal column.

Peculiarities of angiospasm and ischemic complications in ruptures of cerebral arterial aneurysms against the background of occlusive-stenotic lesions of cerebral arteries

Objective – to determine the effect of occlusive-stenotic lesions of cerebral arteries on angiospasm and ischemic complications in patients with ruptured arterial aneurysms against the background of occlusive-stenotic lesions of cerebral arteries. Materials and methods. A retrospective study of the medical histories of 1,147 patients with cerebral artery aneurysms from 2006 to 2022 was conducted. 63 patients were included in the study group because they met the following criteria: surgical treatment; rupture of saccular aneurysms (SAs); the presence of occlusive-stenotic lesions was proven using instrumental examination methods. Patients of the control group had to meet the following criteria: surgical treatment; rupture of SAs; the absence of occlusive-stenotic lesions was proven by means of instrumental examination methods; the gender and age distribution had to match the study group. Of the 126 patients included in this study, there were 76 men (60.32%) and 50 women (39.68%). The age of the patients varied from 31 to 77 years. The average age of patients- 55.9±0.76 years; men – 54.3±0.94 years, women – 58.3±1.19 years. Results. A percentage predominance of patients with high cerebral blood flow velocity (&gt;200 cm/s, which is equal to the velocity with severe grade III vasospasm of the cerebral arteries) in the study group (32.56%) compared with the control group (24.24%) was revealed. Conclusions. The predominance of men among patients of the study group (60.32%) was established. The average age of men with occlusive-stenotic lesions was younger than that of women (men – 54.3±0.94 years, women – 58.3±1.19 years). The difference in age is the largest in the 2nd subgroup of the study group where the severity of stenosis is 50-75% (men - 48.3 years; women - 62 years). Ruptures of arterial aneurysms of the middle cerebral artery occur more often in the presence of stenoses (study group - 25.4%, control group - 12.7%). The neurological status of patients with a hemorrhagic stroke, as a result of the rupture of an arterial aneurysm, is significantly aggravated by occlusive-stenotic lesions due to the occurrence of chronic brain ischemia. The worst prognosis for life and health was in men with a ruptured arterial aneurysm against the background of a 50-75% stenotic lesion and severe vasospasm of the cerebral arteries.

Safety and Efficacy of Levetiracetam for Prevention of Epileptic Seizures in Acute Phase of Intracerebral Bleeding

Background: Epilepsy, characterized by recurrent, unprovoked seizures due to anomalous brain activity, is a significant complication for patients with intracerebral hemorrhage (ICH). The onset of epileptic convulsions during the acute phase of ICH can worsen the patient's prognosis and survival chances, making it crucial to identify a safe and effective method to prevent these seizures. Levetiracetam, a pyrrolidone derivative, is noted for its unique mechanism of action, exceptional tolerability, and advantageous pharmacokinetics, making it efficacious against various types of seizures. Objective: This study aims to evaluate the safety and efficacy of levetiracetam in preventing epileptic seizures during the acute phase of ICH and to determine its impact on neurological outcomes in this patient population. Methods: A cross-sectional investigation was conducted between October 2022 and June 2023 at Pak Emirates Military Hospital in Rawalpindi, Pakistan, involving 85 patients with spontaneous ICH confirmed by CT or MRI within 24 hours of symptom onset. Inclusion criteria included adult patients aged 18 or older, with various forms of ICH, excluding isolated subarachnoid hemorrhage, penetrating wound injury, depressed skull fracture, or early posttraumatic seizure. Patients with a Glasgow Coma Scale (GCS) score of less than 6, serum creatinine level &gt;1.7 mg/dL, history of psychosis, unprovoked seizures, cerebrovascular accidents, traumatic brain injuries, or encephalitis within the previous three years were excluded. Patients were administered an initial loading dose of levetiracetam (1,000 to 1,500 mg), followed by a maintenance dose (500 to 1,500 mg every 12 hours) based on renal function. Continuous electroencephalography (cEEG) monitoring was used to detect seizures for at least the first 72 hours of hospital admission. The primary outcome was the incidence of epileptic seizures during hospitalization, while the secondary outcome was the patient's neurological status at discharge, assessed using the Modified Rankin Scale (mRS). Data were analyzed using descriptive statistics and the Chi-square test, with a p-value of ≤0.05 considered statistically significant. Analyses were conducted using SPSS version 25. Results: The mean age of the patients was 47.89 years (SD=7.46), with 62.35% male and 37.65% female. The mean GCS score at admission was 10.52 (SD=2.13), and the mean volume of ICH was 17.5 ml (SD=3.4). At baseline, 2.35% of patients had GCS scores of 3-5, which improved to 0% after treatment. The percentage of patients with GCS scores of 13-15 increased from 65.88% to 83.52% (p=0.3730). Seizures within the first 7 days occurred in 10.58% of patients, and the overall seizure incidence during hospitalization was 20%. At discharge, 9.41% of patients had an mRS score of 0, and the percentage of patients with an mRS score of 2 increased significantly from 18.18% to 37.64% (p=0.4086*). The percentage of patients with severe disability (mRS score of 5) significantly decreased from 22.72% to 5.68% (p=0.0094*). Conclusion: Levetiracetam is effective in improving neurological outcomes and reducing the incidence of seizures in patients with acute intracerebral hemorrhage, with a manageable safety profile. These findings suggest that levetiracetam can be a valuable addition to therapeutic strategies for managing ICH-related seizures, potentially enhancing patient care and improving health outcomes.

Dialysis disequilibrium syndrome: A case report

Dialysis disequilibrium syndrome (DDS) is a rare syndrome that can occur in patients with severe azotemia undergoing an initial hemodialysis (HD) session. DDS is associated with a more rapid decrease in urea concentration in the blood than in the brain during dialysis. Although severe DDS is less common, the milder forms of DDS may be missed by doctors. A 53-year-old male patient had the main complaint of severe dizziness in the last 10 months accompanied by a sensation of a wobbling head and tinnitus in his right ear. The patient had previously been diagnosed with polycystic kidney disease in 2018 and underwent regular hemodialysis two times a week since June 2019. In the patient's neurological status, cerebellar examination was positive for left dysmetria, left positive past pointing, Romberg test (open eye) fell to the right, and Romberg test (closed eye) fell to the right. There was no nystagmus on the patient's neuro-ophthalmological examination. Patients with kidney failure are at risk of developing DDS, so that appropriate precautions are needed. Due to the variability of symptoms, DDS often goes undiagnosed. Thus, it is important to be aware of the risk factors for DDS so that preventive steps can be taken appropriately. Continuous case reporting will raise awareness and the opportunity for further research to improve outcome in severe cases of DDS. Keywords: Dialysis; Disequilibrium; Dizziness; Polycystic Kidney. Citation: Yahya, Hidayati HB, Sugondo AT, Puspamaniar VA, Firdausa FS. Dialysis disequilibrium syndrome: A case report. Anaesth. pain intensive care 2024;28(1):191−195; DOI: 10.35975/apic.v28i1.2388 Received: October 10, 2023; Reviewed: December 20, 2023; Accepted: January 02, 2024

130 Heterotopia and Neurodevelopmental Outcomes Patients With Prenatal Diagnosis of Myelomeningocele or Myeloschisis

INTRODUCTION: Gray matter heterotopia is a cortical malformation and a known risk factor for seizures and epilepsy. Historically, presence of heterotopia in one or both cerebral ventricles was a concern for postnatal neurological status in patients undergoing fetal closure of myelomeningocele/myeloschisis. There is little information known regarding the overall impact of heterotopia in this patient population. METHODS: A retrospective chart review was conducted for all patients evaluated at the Center of Fetal Diagnosis and Treatment with a diagnosis of myelomeningocele or myeloschisis between June 2016 to March 2023. Gray matter heterotopia was determined from prenatal US and confirmed with prenatal and postnatal MRI. The Bayley Scales of Infant and Toddler Development (edition III and IV) were used for neurodevelopmental assessments. RESULTS: Of 497 patients evaluated with a prenatal diagnosis of myelomeningocele or myeloschisis, 99 were found to have gray matter heterotopia on prenatal MRI. In the postnatal period, 347 patients ultimately delivered at our institution, of which 26 had confirmed gray matter heterotopia on postnatal MRI as well as underwent neurodevelopmental testing. The median age at neurodevelopmental assessment was 13.3 months. The median cognitive and language scores (95 and 99, respectively) were average in those patients with gray matter heterotopia. CONCLUSIONS: This study suggests that the presence of gray matter heterotopia in patients with prenatal diagnosis of myelomeningocele or myeloschisis is not associated with increased cognitive or language delay on neurodevelopmental testing at approximately 1 year of age. These findings can aid clinicians during prenatal consultation regarding fetal repair of spina bifida.

Unilateral biportal endoscopic surgical decompression for symptomatic ossification of the ligamentum flavum – Is it enough to improve the clinical outcome? A case-control study

PurposeOpen decompression is currently the standard surgical procedure for symptomatic OLF. As the minimal invasive method gains popularity, UBE is considered a reliable technique with less complication. However, the outcome is still in question. This study aimed to evaluate and compare UBE versus open surgery in symptomatic OLF cases. MethodsWe evaluated 35 patients with single- or two-level thoracic OLF, underwent decompression by open or UBE. Surgery duration, estimated blood loss, and LOS were recorded as intraoperative parameters. Minimum follow-up was 1 year to evaluate clinical parameters based on the mJOA score, Frankel grade, and recovery rate (RR). ResultsThe UBE procedure showed significant superiority with faster surgery (62.5 min vs. 180 min; p < 0.001), less blood loss (50 mL vs. 250 mL; p < 0.001), and shorter LOS (4 days vs. 6 days; p < 0,001). UBE patients showed notable clinical improvement on the mJOA score at 1 year (8.2 ± 0.18 vs. 6.8 ± 0.24; p = 0.015). Frankel grade improvements seen in both groups with 51.4% of subjects having at least a 1-point upgrade. RR in 1 year resulted in significant recovery in UBE group (RR-UBE 43.2 ± 17 vs. RR-open 26.3 ± 15.3; p < 0.05). No neurological deterioration or significant complication occurred after either procedure. ConclusionThe UBE technique allows faster decompression with less blood loss and shorter LOS compared to open surgery. It was found to be a reliable treatment option in treating OLF with favorable clinical outcomes and improved patient neurological status.

Correlation between Gibbus and Neurological Status in Patients with Tuberculous Spondylitis and its impact after Operative Intervention

Correlation between Gibbus and Neurological Status in Patients with Tuberculous Spondylitis and its impact after Operative Intervention

A Comprehensive Review and Practical Guide of the Applications of Evoked Potentials in Neuroprognostication After Cardiac Arrest.

Cardiorespiratory arrest is a very common cause of morbidity and mortality nowadays, and many therapeutic strategies, such as induced coma or targeted temperature management, are used to reduce patient sequelae. However, these procedures can alter a patient's neurological status, making it difficult to obtain useful clinical information for the reliable estimation of neurological prognosis. Therefore, complementary investigations are conducted in the early stages after a cardiac arrest to clarify functional prognosis in comatose cardiac arrest survivors in the first few hours or days. Current practice relies on a multimodal approach, which shows its greatest potential in predicting poor functional prognosis, whereas the data and tools to identify patients with good functional prognosis remain relatively limited in comparison. Therefore, there is considerable interest in investigating alternative biological parameters and advanced imaging technique studies. Among these, somatosensory evoked potentials (SSEPs) remain one of the simplest and most reliable tools. In this article, we discuss the technical principles, advantages, limitations, and prognostic implications of SSEPs in detail. We will also review other types of evoked potentials that can provide useful information but are less commonly used in clinical practice (e.g., visual evoked potentials; short-, medium-, and long-latency auditory evoked potentials; and event-related evoked potentials, such as mismatch negativity or P300).

Compressive myelopathy from diffuse spinal dural calcifications in a patient with end-stage renal disease: illustrative case.

Diffuse spinal dural calcification is a rare disorder associated with hyperparathyroidism, including the secondary forms associated with renal failure, osteodystrophy, and chronic hypocalcemia. Here, the authors report a rare case of diffuse dural calcification causing spinal cord compression with myelopathy, requiring decompressive surgery with duraplasty to achieve adequate decompression. A 46-year-old male with a history of renal failure on dialysis presented with 2 months of progressive neuropathic pain, lower-extremity weakness, and nonsustained clonus. Spine imaging showed severe renal osteodystrophy with multilevel compression fractures and diffuse dural calcifications with areas of invagination causing severe spinal cord compression. Decompressive surgery was recommended. In surgery, a thickened and calcified dura was encountered with areas of buckling causing spinal cord compression. The invaginated area of the dura was resected and reconstructed with patch duraplasty. The patient's neurological status remained unchanged postoperatively, and at the 6-month follow-up, the patient reported significant improvement in pain and muscle spasms. Diffuse dural calcifications are a rare complication of prolonged dialysis and secondary hyperparathyroidism. When there is resultant spinal cord compression, this condition requires an intradural approach that addresses the thickened, calcified dura directly to obtain adequate spinal cord decompression.

Ruptures of arterial aneurysms of the brain and stenosis of the carotid basin: clinic, diagnosis

Objective – to investigate the clinical and morphological characteristics of the manifestations of the rupture of arterial aneurysms of the brain in patients with occlusive-stenotic lesions of the cerebral arteries.Materials and methods. 1147 case histories of patients with aneurysmal disease of the cerebral arteries who underwent comprehensive examination and treatment in the Department of Neurosurgical Pathology of Head and Neck Vessels with X-ray Surgical Department «Romodanov Institute of Neurosurgery NAMS of Ukraine» since 2006 until 2022. The medical histories of 126 patients who were included in this study and divided into two groups were studied in detail. The criteria for inclusion in the main group (38 men and 25 women) were: surgical treatment; rupture of arterial aneurysm the presence (proven using instrumental examination methods) of occlusive-stenotic lesions.The criteria for inclusion in the control group (38 men and 25 women) were: surgical treatment; rupture of arterial aneurysm; absence (proven by means of instrumental examination methods) of occlusive-stenotic lesions; the gender and age distribution had to match the main group.Among the patients included in this study, there were 76 men (60.32 %) and 50 women (39.68 %). The age of the patients varied from 31 to 77 years. The average age of patients ‒ 55.9 ± 0.76 years. Results. The Hunt‒Hess severity of patients was approximately the same between the main and control groups. When evaluated by the World Federation of Neurologican Surgeons (WFNS) and Glasgow Coma scale (GCS), more patients in the control group had a lighter score. Aneurysms of the anterior cerebral-anterior connecting artery complex prevailed in both groups. A higher frequency of arterial aneurysms of the middle cerebral artery was revealed among patients of the main group (main group ‒ 27.0 %, comparison group 15.8 %). The higher number of multiple aneurysms in the main group (the main group ‒ 25.4 %, the controlgroup ‒ 12.7 %) and the smaller number of miliary aneurysms and the larger number of large aneurysms in the main group may indicate the predominance of congenital etiological factors common to both pathologies in the development of the disease until the rupture of the arterial aneurysm.Conclusions. Gender differences were established with a predominance of men among patients of the main group (60.32 %). The average age of men with occlusive-stenotic lesions was lower than that of women (men – 54.3±0.94 years, women – 58.3±1.19 years). The difference in age is especially pronounced in the subgroup of the main group where the severity of stenosis is 50‒75 % (men ‒ 48.3 years; women ‒ 62.0 years).The neurological status of patients with a hemorrhagic stroke, as a result of the rupture of an arterial aneurysm, is significantly aggravated by occlusive-stenotic lesions due to the occurrence of chronic brain ischemia. The worst prognosis is in men with a ruptured arterial aneurysm and a 50‒75 % stenotic lesion.

Thoracoscopic thymectomy for myasthenia gravis and non-invasive thymoma after COVID-19 pneumonia

Modern guidelines have identified thoracoscopic thymectomy as a preferable option for myasthenia gravis and non-invasive thymoma. In the era of the new coronavirus infection, it is relevant to develop protocols for anesthetic and perioperative support of patients undergoing thymectomy for myasthenia gravis after COVID-associated pneumonia (CAP). We present the results of thoracoscopic thymectomies in patients after CAP. Multidisciplinary team should determine therapeutic support, the need for plasmapheresis and thymectomy. Plasmapheresis and glucocorticosteroids are effective in addition to anticholinesterase therapy at the stages of perioperative support for correction of neurological status in patients with myasthenia combined with chronic obstructive pulmonary disease and pulmonary hypertension. Outpatient direct anticoagulants are advisable considering the need for prolonged postoperative prevention of thrombotic events.

THE INFLUENCE OF VESSEL CURVATURE AND THROMBUS COMPOSITION ON THE EFFECTIVENESS AND OUTCOMES OF THROMBECTOMY IN THE CASE OF ACUTE ISCHEMIC STROKE

Introduction. It is believed that vascular anatomy has a direct influence on the complexity and course of mechanical thrombectomy, and its outcome determines the degree of reperfusion and clinical effect.&#x0D; Aim. To analyze the influence of the curvature of the intracranial arteries and the composition of the thrombus on the results of thrombectomy.&#x0D; Materials and methods. 64 patients who underwent mechanical thrombectomy for acute proximal occlusion of the ICA or MCA were prospectively examined. (44man/20women among them, the age of the patients ranged from 47-89years (67.2±1.2). The study was performed by measuring the ICA-M1 angle on angiograms in direct projection. Angles were compared between patients with successful (mTICI group 2b/3) and unsuccessful (mTICI group 0-2a) reperfusion. The functional result was evaluated according to the mRS scale as positive (0-3) and negative (4-5). Removed thrombi were examined by light microscopy with hematoxylin-eosin and orange-red-blue staining.&#x0D; Results. Among patients of the mTICI 2b/3 group, a larger angle of the ICA-M1 was measured (126.4±2.8°) compared to patients in the mTICI 0-2a group - 107.1±4.9° (p=0.05). Among patients with 1-2 passages, statistically significantly larger ICA-M1 angles were recorded (129.8±3.3°) than among patients with a number of passages &gt;2 (109.2±5,7°, p&lt;0.02). The duration of mechanical thrombectomy was &lt;60min among patients with larger angles of the ICA-M1 (127.6±4.4° vs. 119.6±4.5°) than in patients with long interventions (&gt;60 min) (p&lt;0.05). Successful reperfusion (group mTICI 2b/3) was achieved in 47 (73.4%) patients. A clinically positive result(mRS 0-3) was observed among 37(57.8%) patients.&#x0D; During microscopic examination of thrombi among patient groups mTICI 0/2a, fibrin threads with signs of aging with purple and blue color were present on the periphery (24-48hours). With a favorable outcome of the operation, the coagulated fibrin fibers were stained red (&lt;16hours).&#x0D; Conclusions. With a smaller curvature of the ICA and its branches, and in the presence of "fresh" thrombi, the efficiency of operations increases, and the number of passages and the duration of mechanical thrombectomy decrease. The neurological status of patients at admission correlates with the functional outcome at the time of discharge.

Pituitary apoplexy associated with gram-negative meningitis following transsphenoidal surgery

BackgroundPituitary apoplexy (PA) is a rare but potentially life-threatening condition. While it is uncommon, it can present with findings that are clinically indistinguishable from acute bacterial meningitis. We report an unusual case of simultaneous coexistence of bacterial meningoencephalitis and pituitary apoplexy following transsphenoidal surgery (TSS) for pituitary macroadenoma, emphasizing the possibility of coexistence of the two entities.Case presentationA 62-year-old man was admitted with a moderate headache, gait disturbance, and progressively decreasing vision. Sellar magnetic resonance imaging showed a giant pituitary tumor of 4 × 5 cm with invasion of the cavernous sinus bilaterally, and a mass effect on the optic chiasm. The patient underwent a TSS and partial resection of a giant pituitary tumor. On postoperative day 11, he presented with an acute, severe headache and altered sensorium. An urgent computed tomography (CT) scan revealed hemorrhagic swelling of the residual. A complete analysis of the anterior pituitary hormones revealed panhypopituitarism. Administering steroid ameliorated the clinical features, but after decreasing the dose, the patient continued to deteriorate in his neurological status, a high fever, and marked stiffness were noted on postoperative day 14. Given the neck stiffness, leukocytosis, and high C-reactive protein level, acute meningitis was suspected, and the cerebrospinal fluid (CSF) was tested, which was consistent with acute bacterial meningitis. In the results of the bacterial cultures of the CSF, E. coli was identified and switched to ceftriaxone. The patient's neurological status and body temperature improved gradually. CSF test results returned to normal levels, and ceftriaxone was discontinued on day 10.ConclusionsThis is a report on a case of a giant pituitary tumor that developed late postoperative PA after having undergone a partial tumor resection. A postoperative CT scan showed hemorrhagic expansion of the residual tumor mass. Further, the patient exhibited typical symptoms of acute meningoencephalitis, the result of the cultures of the CSF was positive, and the patient's general condition deteriorated. In addition, laboratory findings indicated leukocytosis, an elevated C-reactive protein level, and neutrophilic pleocytosis. We highlighted diagnostic challenges and therapeutic delays arising as a result of rare concomitance.

Abstract 390: Pre-Hospital Administered Adrenaline in the Presence of a Physician and Neurological Status of Patients With Out-of-Hospital Cardiac Arrest: A Multi-Center Prospective Cohort Study

Background: Little is known about whether pre-hospital administered adrenaline with a physician present could improve the outcome of patients with cardiac arrest. Hypothesis and Aim: We aimed to test the hypothesis that pre-hospital administered adrenaline provided in the presence of a physician could improve neurological survival of patients with a specific type of first-confirmed cardiac rhythm following cardiac arrest compared with pre-hospital administered adrenaline provided in the absence of a physician. Methods: This prospective multi-center cohort study enrolled consecutive patients who were transported to 95 participating hospitals in Japan after out-of-hospital cardiac arrest and later underwent resuscitation at a hospital between June 1 2014 and December 31 2020. We included patients who were administered pre-hospital adrenaline under the presence or absence of a physician, and who were ≥18 years of age with cardiac arrest of a medical etiology. Primary outcome was a favorable neurological outcome (Cerebral Performance Category score of 1 or 2) one month after cardiac arrest. Whether the carotid artery was pulsating and 3-lead electrocardiogram monitor confirmed the first cardiac rhythm. Based on previous findings, those with the first-confirmed cardiac rhythm were subdivided into the non-shockable and shockable groups. Multivariable logistic regression analysis was performed on propensity score-matched patients. Results: We analyzed 11,711 patients. Among the 10,113 patients in the non-shockable group, 0.6% (N = 64) had a favorable neurological outcome. The adjusted odds ratio for a favorable neurologic outcome of pre-hospital administered adrenaline under the presence of a physician was 3.94 (95% confidence interval (CI): 1.58-11.4), compared with the absence of a physician. Of 1,598 patients in the shockable group, 10.3% (N = 164) had a favorable neurological outcome with an adjusted odds ratio of 1.30 (95% CI: 0.73-2.35). Conclusion: This prospective multi-center cohort study showed that pre-hospital administered adrenaline in the presence of a physician was significantly associated with a higher favorable neurological outcome in non-shockable patients with cardiac arrest.

Developing and Validating a New Model to Predict the Risk of Poor Neurological Status of Acute Ischemic Stroke After Intravenous Thrombolysis.

The objective of this study was to develop and validate a predictive model for the risk of poor neurological status in in-hospital patients with acute ischemic stroke (AIS) after intravenous thrombolysis. This 2-center retrospective study included patients with AIS treated at the Advanced Stroke Center of the Second Hospital of Hebei Medical University and Baoding No.1 Central Hospital between January 2018 and January 2020). The neurological function status at day 7 of AIS onset was used as the endpoint of the study, which was evaluated using the National Institute of Health Stroke Scale (NIHSS) score. A total of 878 patients were included in the study and divided into training (n=652) and validation (n=226) sets. Seven variables were selected as predictors to establish the risk model: age, NIHSS before thrombolysis (NIHSS1), NIHSS 24 hours after thrombolysis (NIHSS3), high-density lipoprotein, antiplatelet, cerebral computed tomography after thrombolysis (CT2), and lower extremity venous color Doppler ultrasound. The risk prediction model achieved good discrimination (the areas under the Receiver Operating Characteristic curve in the training and validation sets were 0.9626 and 0.9413, respectively) and calibration (in the training set Emax=0.072, Eavg=0.01, P=0.528, and in the validation set Emax=0.123, Eavg=0.019, P=0.594, respectively). The decision curve analysis showed that the model could achieve a good net benefit. The prediction model obtained in this study showed good discrimination, calibration, and clinical efficacy. This new nomogram can provide a reference for predicting the risk of poor neurological status in patients with acute ischemic stroke after intravenous thrombolysis.

Comparison of Motor Evoked Potentials Neuromonitoring Following Pre- and Postoperative Transcranial Magnetic Stimulation and Intraoperative Electrical Stimulation in Patients Undergoing Surgical Correction of Idiopathic Scoliosis.

The relationships between the results of pre- and intraoperative motor evoked potential recordings during neuromonitoring and whether idiopathic scoliosis (IS) surgical correction improves the spinal efferent transmission have not been specified in detail. This study aims to compare the results of surface-recorded electromyography (EMG), electroneurography (ENG, M, and F-waves), and especially motor evoked potential (MEP) recordings from tibialis anterior muscle (TA) bilaterally in 353 girls with right idiopathic scoliosis (types 1-3 according to Lenke classification). It has not yet been documented whether the results of MEP recordings induced by transcranial single magnetic stimulus (TMS, pre- and postoperatively) and trains of electrical stimuli (TES; intraoperatively in T0-before surgery, T1-after pedicle screws implantation, and T2-after scoliosis curvature distraction and derotation following two-rod implantation) can be compared for diagnostic verification of the improvement of spinal cord neural transmission. We attempted to determine whether the constant level of optimal anesthesia during certain surgical steps of scoliosis treatment affects the parameters of MEPs recorded during neuromonitoring procedures. No neurological deficits have been observed postoperatively. The values of amplitudes but not latencies in MEP recordings evoked with TMS in IS patients compared before and after surgery indicated a slight improvement in efferent neural transmission. The results of all neurophysiological studies in IS patients were significantly asymmetrical and recorded worse on the concave side, suggesting greater neurological motor deficits at p = 0.04. The surgeries brought significant improvement (p = 0.04) in the parameters of amplitudes of sEMG recordings; however, the consequences of abnormalities in the activity of TA motor units were still reflected. ENG study results showed the symptoms of the axonal-type injury in peroneal motor fibers improving only on the concave side at p = 0.04, in parallel with F-wave parameters, which suggests that derotation and distraction might result in restoring the proper relations of the lumbar ventral roots in the spinal central canal, resembling their decompression. There were no significant differences detected in the amplitudes or latencies of MEPs induced with TMS or TES when comparing the parameters recorded preoperatively and intraoperatively in T0. The amplitudes of TES-evoked MEPs increased gradually at p = 0.04 in the subsequent periods (T1 and T2) of observation. A reduction in MEP latency at p = 0.05 was observed only at the end of the IS surgery. Studies on the possible connections between the level of anesthesia fluctuations and the required TMS stimulus strength, as well as the MEP amplitude changes measured in T0-T2, revealed a lack of relationships. These might not be the factors influencing the efferent transmission in spinal pathways beside the surgical procedures. Pre- (TMS-evoked) and intraoperative (TES-evoked) recordings are reliable for evaluating the patient's neurological status before and during surgical scoliosis correction procedures. An increase in MEP amplitude parameters recorded on both sides after scoliosis surgery proves the immediate improvement of the total efferent spinal cord transmission. Considering comparative pre- and postoperative sEMG and ENG recordings, it can be concluded that surgeries might directly result in additional lumbar ventral root decompression. We can conclude that MEP parameter changes are determined by the surgery procedures during neuromonitoring, not the anesthesia conditions if they are kept stable, which influences a decrease in the number of false-positive neuromonitoring warnings.

Single-center experience in 127 adult patients, mono or dual artificial liver support therapy, in patients with acute liver failure.

Acute liver failure (ALF) is a serious condition characterized by sudden liver dysfunction, jaundice and hepatic encephalopathy. Its mortality rate of approximately 80% underscores the urgent need for effective treatments. Supportive extracorporeal therapies (SET), which temporarily support liver function and remove toxins, have shown promise in improving outcomes in acute liver failure (ALF). The aim of this study was to compare the outcomes of dual supportive extracorporeal therapy (SET) and mono supportive extracorporeal therapy in patients with acute liver failure. A total of 127 patients with acute liver failure were included in this retrospective, single-center study. Of these, 62 patients received dual supportive extracorporeal therapy and 65 patients received mono supportive extracorporeal therapy. Primary endpoints were survival without the need for liver transplantation and mortality. Secondary endpoints included resolution of encephalopathy and normalization of International Normalized Ratio (INR). In the dual supportive extracorporeal therapy group, 59.6% of patients survived without the need for liver transplantation, while 27.4% achieved recovery with liver transplantation. The mortality rate in this group was 12.9%. Significant regression of encephalopathy grade was observed in 87% of patients, and the 1 year mortality rate for liver transplant recipients was 10.7%. In the mono supportive extracorporeal therapy group, 61.5% of patients experienced a successful recovery without the need for liver transplantation, with a mortality rate of 29.2%. Significant improvement in the grade of encephalopathy was observed in 70.7% of patients. Both dual supportive extracorporeal therapy (CVVHDF and PE) and mono supportive extracorporeal therapy (PE) were associated with significant improvements in renal and hepatic biochemical parameters, blood ammonia levels, and neurological status in patients with acute liver failure associated with grade III-IV hepatic encephalopathy. In particular, dual support was associated with improved hemodynamic stability, lactic acidosis and acid-base balance. Survival in acute liver failure in our retrospective cohort using a protocolized approach to extracorporeal therapies is higher compared to previously published large ALF studies. This protocolized approach warrants further prospective studies.

Caregiver Burden of Patients With Huntington's Disease in South Korea.

This is the first prospective cohort study of Huntington's disease (HD) in Korea. This study aimed to investigate the caregiver burden in relation to the characteristics of patients and caregivers. From August 2020 to February 2022, we enrolled patients with HD from 13 university hospitals in Korea. We used the 12-item Zarit Burden Interview (ZBI-12) to evaluate the caregiver burden. We evaluated the clinical associations of the ZBI-12 scores by linear regression analysis and investigated the differences between the low- and high-burden groups. Sixty-five patients with HD and 45 caregivers were enrolled in this cohort study. The average age at onset of motor symptoms was 49.3 ± 12.3 years, with an average cytosine-adenine-guanine (CAG)n of 42.9 ± 4.0 (38-65). The median ZBI-12 score among our caregivers was 17.6 ± 14.2. A higher caregiver burden was associated with a more severe Shoulson-Fahn stage (p = 0.038) of the patients. A higher ZBI-12 score was also associated with lower independence scale (B = -0.154, p = 0.006) and functional capacity (B = -1.082, p = 0.002) scores of patients. The caregiving duration was longer in the high- than in the low-burden group. Caregivers' demographics, blood relation, and marital and social status did not affect the burden significantly. HD patients' neurological status exerts an enormous impact on the caregiver burden regardless of the demographic or social status of the caregiver. This study emphasizes the need to establish an optimal support system for families dealing with HD in Korea. A future longitudinal analysis could help us understand how disease progression aggravates the caregiver burden throughout the entire disease course.