Lower Limb Paralysis Research Articles

Aortic dissection diagnosed on stroke computed tomography protocol: a case report

BackgroundAortic dissection is one of the causes of stroke. Because cerebral infarction with aortic dissection is a contraindication to intravenous recombinant tissue plasminogen activator (rt-PA) therapy, exclusion of aortic dissection is necessary prior to its administration. However, imaging takes time to provide a diagnosis, possibly causing delays in surgical treatment.Case presentationA 65-year-old Japanese female patient was transported to the hospital for a suspected stroke, with back pain and left upper and lower extremity palsy which occurred while eating. Upon arrival at the hospital, the left lower limb paralysis had improved, but the left upper limb paralysis remained. Right back pain had also developed. A plain head computed tomography (CT) scan performed 110 minutes after onset showed no acute bleeding or infarction. Subsequent CT perfusion (CTP) showed acute perfusion disturbance in the right hemisphere without infarction, known as ischemic penumbra. The four-dimensional maximum-intensity projection image reconstructed from CTP showed a delayed enhancement at the right internal carotid and right middle cerebral arteries compared to the contralateral side, suggesting a proximal vascular lesion. Contrast helical CT from the neck to abdomen revealed an acute aortic dissection of Stanford type A with false lumen patency. The dissection extended to the proximal right common carotid artery. The patient underwent an emergency total arch replacement and open stent graft. After recovering well, the patient was ambulatory upon discharge from the hospital. The combination of plain head CT, CTP, and helical CT scan from the neck to abdomen enabled us to evaluate for stroke and aortic dissection within a short amount of time, allowing for early therapeutic intervention.ConclusionsWhen acute stroke is suspected due to neurological deficits, plain head CT is the first choice for imaging diagnosis. The addition of cervical CT angiography can reliably exclude stroke due to aortic dissection. CTP can identify ischemic penumbra, which cannot be diagnosed by plain head CT or diffusion-weighted magnetic resonance imaging. These combined stroke CT protocols helped us avoid missing an aortic dissection.

Rare Atypical Presentation of a Neuroblastoma of Posterior Mediastinum

Abstract Introduction Neuroblastoma is the third most common malignancy and one of the most common neurogenic tumors of posterior mediastinum in the pediatric age group. A posterior mediastinal tumor causing spinal cord compression is an important example of an oncologic emergency arising from a neurogenic tumor. We present a rare case of posterior mediastinum neuroblastoma, with exclusive lower limb weakness presenting at an unusually older age. Case Presentation A 6-year-old girl reported with upper back ache and sudden onset progressive bilateral lower limb weakness, with difficulty in urination for 10 days. The weakness had progressed to paraplegia on the day of presentation. On examination, the child was observed to have loss of tone and power in both lower limbs and bilateral extensor plantar reflex. Chest X-ray showed heterogeneous opacity involving most of the left lung. Contrast-enhanced MRI showed posterior mediastinal tumor, extending into spinal canal. Patient underwent D3 to D6 laminectomy with subtotal tumor excision and spinal decompression. Crush biopsy showed round cell tumor, and final histopathological examination revealed poorly differentiated neuroblastoma, which was strongly positive for neuron-specific enolase on immunohistochemistry. The surgery was followed by chemotherapy, and the patient remained symptom free on 2-year follow-up. Discussion The presenting symptoms in case of thoracic neuroblastoma may include airway obstruction and chronic cough. Sometimes, it may present with weakness, limping, paralysis, and bladder and bowel disturbances in case of spinal cord involvement. Posterior mediastinal neuroblastoma presenting with paraparesis is uncommon. In our case, the child presented with isolated lower limb flaccidity with no other classical symptoms. To the best of our knowledge and thorough study, only four cases of posterior mediastinum neuroblastoma presenting with lower limb paralysis has been published in the English literature to date. Conclusion Tumor usually presents with pressure symptoms, caused by the mass in the posterior mediastinum, but it’s almost exclusive occurrence in the pediatric population warrants a thorough investigation in patients presenting with not only a symptomatic mass but also exclusive lower limb neurological symptoms.

Design of sitting lower limb rehabilitation training robot

Based on the theory of sports rehabilitation medicine, aiming at the needs of early, middle and late rehabilitation training of patients with lower limb paralysis, a sitting lower limb rehabilitation robot is designed to train muscles with impaired motor function of the limbs. The Innovative design of the lower limb rehabilitation training robot consists two parts. They are the lower limb rehabilitation mechanism and the seat auxiliary mechanism, which can restore and reconstruct the impaired motor function of patients to the greatest extent.

Lathyrism and Socioeconomic Disparities: A Neglected Public Health Problem in Northeast Ethiopia.

Lathyrism is an incurable neurological disorder, resulting from excessive consumption of grass pea (Lathyrus sativus), which clinically manifests as paralysis of lower limbs. Because of the high production of grass peas, a large number of people are expected to be affected by the disease in Northeast Ethiopia. However, there is no comprehensive study that quantified the magnitude of the problem. Therefore, in this study, we determined the prevalence of lathyrism and socioeconomic disparities in Northeast Ethiopia. A community-based cross-sectional study was used which used a quantitative method of data collection from January to February 2019. Data were collected from a total of 2,307 inhabitants in the study area using structured questionnaires. Lathyrism cases were identified using a case definition of symmetrical spastic leg weakness, and subacute or insidious onset, with no sensory deficit, and with a history of grass pea consumption before and at the onset of paralysis. The majority (56.8%) of participants were male, and 34.7% were aged 45 years or older. Overall, the prevalence of lathyrism was 5.5%, and it was higher in males (7.9%) than in females (2.5%). Moreover, the prevalence was higher among farmers (7.0%) than merchants (0.3%), very poor economic status (7.2%) than very rich (1.1%), who produced (9.6%) grass pea than not produced (0.9%), and those who used clay pottery (6.2%) than metal (4.8%) for cooking. The prevalence of lathyrism in Northeast Ethiopia is remarkably high. Therefore, we recommend lathyrism to be among the list of reportable health problems and incorporated in the national routine surveillance system.

Application of Extradural Nerve Root Transfer in the Restoration of Lower Limb Function in Spinal Cord Injury: Hypothesis and a Cadaver Feasibility Study.

Two fresh-frozen and six formalin-fixed cadavers were included in the study. To ascertain whether transferring T9 or T11 ventral root (VR) to L2 VR and T10 or T12 VR to L3 VR in restoring lower limb function after spinal cord injury is anatomically feasible. Lower limb paralysis impairs the quality of the life and places burden on the whole society. However, no significant improvement in this area was achieved during recent years. In the present study, two fresh-frozen and six formalin-fixed cadavers were dissected to confirm the anatomical feasibility. A limited laminectomy was performed to expose the T9-L3 extradural nerve roots. T9 and T10 VR were anastomosed to L2 and L3 VR respectively, or T11 and T12 VR were anastomosed to L2 and L3 VR respectively. The pertinent distances between the donor and recipient nerves were measured and H&E staining was used to detect the axon number and cross-section area of each VR. The limited incision was performed to expose the T9-L3 nerve root. According to the anatomic landmark of dorsal root ganglion, each VR could be isolated from each extradural nerve root. The T9 or T11 VR needs sural nerve graft to be transferred to L2 VR, and T10 or T12 VR also needs a nerve bridge to connect to L3 VR. The nerve numbers of T9, T10, T11, T12, L2, and L3 VRs and the sural nerves were measured respectively. The cross-section areas of T9, T10, T11, T12, L2, and L3 VRs and sural nerves were measured respectively. Our study suggested that application of transferring T9 or T11 VR to L2 VR and T10 or T12 VR to L3 VR in restoring lower limb function is anatomically feasible.Level of Evidence: 5.

Individualized predictions of early isolated distal deep vein thrombosis in patients with acute ischemic stroke: a retrospective study

BackgroundAlthough isolated distal deep vein thrombosis (IDDVT) is a clinical complication for acute ischemic stroke (AIS) patients, very few clinicians value it and few methods can predict early IDDVT. This study aimed to establish and validate an individualized predictive nomogram for the risk of early IDDVT in AIS patients.MethodsThis study enrolled 647 consecutive AIS patients who were randomly divided into a training cohort (n = 431) and a validation cohort (n = 216). Based on logistic analyses in training cohort, a nomogram was constructed to predict early IDDVT. The nomogram was then validated using area under the receiver operating characteristic curve (AUROC) and calibration plots.ResultsThe multivariate logistic regression analysis revealed that age, gender, lower limb paralysis, current pneumonia, atrial fibrillation and malignant tumor were independent risk factors of early IDDVT; these variables were integrated to construct the nomogram. Calibration plots revealed acceptable agreement between the predicted and actual IDDVT probabilities in both the training and validation cohorts. The nomogram had AUROC values of 0.767 (95% CI: 0.742–0.806) and 0.820 (95% CI: 0.762–0.869) in the training and validation cohorts, respectively. Additionally, in the validation cohort, the AUROC of the nomogram was higher than those of the other scores for predicting IDDVT.ConclusionsThe present nomogram provides clinicians with a novel and easy-to-use tool for the prediction of the individualized risk of IDDVT in the early stages of AIS, which would be helpful to initiate imaging examination and interventions timely.

Lower Limb Joint Nursing and Rehabilitation System Based on Intelligent Medical Treatment.

With the aggravation of the problem of aging population, all kinds of lower limb paralysis caused by various diseases occur frequently. People's demand for lower limb nursing and rehabilitation treatment is growing. In this paper, combined with intelligent medical technology and lower limb kinematics model, this paper proposes to build a lower limb joint nursing and rehabilitation system based on intelligent medical treatment. It is expected that, through the following limb joint rehabilitation robot as the main rehabilitation means, a smart nursing rehabilitation system which can quickly respond to users and realize remote rehabilitation nursing can be designed. First of all, it is clear that the main body of the lower limb joint rehabilitation system consists of the robot body and the state display system. Then, the sensor, amplifier, and data acquisition card are set in the data acquisition system, and the plantar balance force is detected using a FlexiForce film pressure sensor. The final control system mainly includes the main control module program and the lower limb action recognition program. The motor control software adopts PID regulation method, and the lower limb action recognition adopts SVM one-to-one classification method. After the construction of lower limb joint nursing and rehabilitation system, the accuracy rate of action recognition and classification was tested. In the third experiment, the accuracy of all the movements was 100%. Then, the joint displacement and angle changes of the experimenter assisted by the system were analyzed. The experimenter's knee joint and hip joint show a normal walking state, and the joint angle changes tend to be normal. Ten out of 55 rehabilitation system users were randomly selected for interview survey. The total scores of operation convenience, wearing comfort, intensity suitability, and movement science of the system were 90, 83, 84, and 91, respectively. This shows that the rehabilitation action designed by the system is scientific and easy to operate and can be put into use in rehabilitation training after improving the wearing comfort.

Decision Tree Algorithm Identifies Stroke Patients Likely Discharge Home After Rehabilitation Using Functional and Environmental Predictors

Background and purposeThe importance of environmental factors for stroke patients to achieve home discharge was not scientifically proven. There are limited studies on the application of the decision tree algorithm with various functional and environmental variables to identify stroke patients with a high possibility of home discharge. The present study aimed to identify the factors, including functional and environmental factors, affecting home discharge after stroke inpatient rehabilitation using the machine learning method. MethodThis was a cohort study on data from the maintained database of all patients with stroke who were admitted to the convalescence rehabilitation ward of our facility. In total, 1125 stroke patients were investigated. We developed three classification and regression tree (CART) models to identify the possibility of home discharge after inpatient rehabilitation. ResultsAmong three models, CART model incorporating basic information, functional factor, and environmental factor variables achieved the highest accuracy for identification of home discharge. This model identified FIM dressing of the upper body (score of ≤2 or >2) as the first single discriminator for home discharge. Performing house renovation was associated with a high possibility of home discharge even in patients with stroke who had a poor FIM score in the ability to dress the upper body (≤2) at admission into the convalescence rehabilitation ward. Interestingly, many patients who performed house renovation have achieved home discharge regardless of the degree of lower limb paralysis. ConclusionWe identified the influential factors for realizing home discharge using the decision tree algorithm, including environmental factors, in patients with convalescent stroke.

Acute cauda equina syndrome due to lumbar spinal stenosis caused by prolonged supine position during cardiac catheterization: a case report

Background: Cauda equina syndrome (CES) is a severe neurologic condition marked by progressive loss of function of the neurologic elements in the spinal canal below the termination of the spinal cord. This article reports an instructive case of CES with acute aggravation of neuropathy after catheter ablation for atrial fibrillation. Patient concerns: A 63-year-old Japanese man underwent catheter ablation for atrial fibrillation. Because he complained of severe low back pain and numbness in the posterior of both lower limbs while in the supine position, he was given analgesia with pentazocine and sedated with propofol, and the procedure continued. He was then forced to maintain lumbar extension while in the supine position for 13 hours. After the treatment, he noticed urination disor-der, numbness, and paralysis of both lower limbs. Diagnosis: Neurological findings included sensory impairment and motor deficit of L5 and below, including bowel/bladder dysfunction. Lumbar magnetic resonance imaging showed severe lumbar spinal stenosis at L4-L5. He was diagnosed with CES due to lumbar spinal stenosis. Interventions: The patient received emergency surgery for L4-L5 decompression. Decompression of the spinal canal was achieved 33 hours after the start of catheterization. Outcomes: The patient’s leg symptoms improved immediately after surgery, and he was able to walk with a walker. On postoperative day 6, the urinary catheter was removed. However, he experienced urinary retention and needed intermittent self-directed urination. Five months after surgery, he was able to urinate on his own, and completed the intermittent self-directed urination. Nine months after surgery, his muscle strength had recovered almost completely, and he was able to walk with a cane. However, bladder dysfunction such as frequent urination and residual urination remained 4 years after surgery. Lessons: If the supine position elicits low back pain and leg numbness, the presence of lumbar spinal stenosis should be considered. Forcing patients with such symptoms into a sustained posture can lead to CES.

A case of paralysis of both lower limbs due to PJK after adult spinal deformity surgery

A case of paralysis of both lower limbs due to PJK after adult spinal deformity surgery

Case Report: A patient with extreme hyperkalemia beats all the odds

Hyperkalemia is a common finding in patients in hemodialysis and is typically classified as mild, moderate or severe. Severe hyperkalemia is a complex and life-threatening clinical entity, closely associated with increased mortality rates. It generally presents with ascending muscle weakness and paralysis, cardiac arrhythmias and specific ECG changes. Herein, we present the case of a 30-year-old patient with end-stage renal disease, on hemodialysis. He presents to his hemodialysis session with complaints of progressive weakness and paralysis of his lower extremities, palpitations and dyspnea. His last session was 5 days prior to his ER presentation, after having missed 2 sessions. Laboratory studies revealed a serum potassium level of 10.9 mg/ dL. Intravenous calcium infusion was administered urgently and subsequently underwent urgent hemodialysis. The next day he underwent another session due to the post-hemodialysis rebound effect, but on physical examination the lower limb paralysis had improved and normal, sinus rhythm was present. Considering its silent development and ambiguous clinical presentation, hyperkalemia should invariably be considered in patients with CKD presenting with cardiac and neurological symptoms. Reported cases of severe hyperkalemia with potassium concentrations higher than 10 mg/dL, as in the case of our patient, are sparse and represent rapidly deteriorating, life-threatening conditions, requiring emergent medical interventions to prevent fatal cardiac arrhythmias.

A case of primary intramedullary spinal cord lymphoma diagnosed by spinal cord biopsy of long spinal cord lesions showing persistent gadolinium contrast enhancement

An 82-year-old man presented with subacute bilateral lower limb paralysis, deep sensory disturbance, and vesico-rectal disturbance. MRI of the spinal cord revealed a large gray matter-dominant lesion extending from the medulla oblongata to the lower thoracic spinal cord. The patient was treated with steroid-pulse therapy for myelitis, but without symptomatic improvement. A spinal cord biopsy was performed for treatment-resistant myelopathy, and histopathology revealed a diffuse large B-cell lymphoma, that was diagnosed as a primary intramedullary spinal cord lymphoma because systemic examination didn't show any other findings suggestive of malignant lymphoma. A spinal cord biopsy is necessary for the definitive diagnosis of this disease, but in the case of poor response to treatment and a progressive course, intramedullary malignant lymphoma should be considered if there is a persistent elevation of CSF IL-10 or a prolonged contrast effect.

Immunopathogenesis and Cellular Interactions in Human T-Cell Leukemia Virus Type 1 Associated Myelopathy/Tropical Spastic Paraparesis

HTLV-1-Associated Myelopathy/Tropical Spastic Paraparesis (HAM/TSP) is a neuropathological disorder in 1–3% of individuals infected with Human T-lymphotropic virus 1 (HTLV-1). This condition is characterized by progressive spastic lower limb weakness and paralysis, lower back pain, bladder incontinence, and mild sensory disturbances resembling spinal forms of multiple sclerosis. This disease also causes chronic disability and is therefore associated with high health burden in areas where HTLV-1 infection is endemic. Despite various efforts in understanding the virus and discovery of novel diagnostic markers, and cellular and viral interactions, HAM/TSP management is still unsatisfactory and mainly focused on symptomatic alleviation, and it hasn’t been explained why only a minority of the virus carriers develop HAM/TSP. This comprehensive review focuses on host and viral factors in association with immunopathology of the disease in hope of providing new insights for drug therapies or other forms of intervention.

Development of Stand-walking Simulator for Rehabilitation Training

A rehabilitation equipment is developed by mechanical and electronic engineering principle based on the need of rehabilitation training for patients with paraplegia. The device can prevent complications such as palsy bedsores and deep venous thrombosis. The device effectively reduces the labor intensity of the rehabilitation staff or family members to carry the patient's body, and promotes the physical and psychological rehabilitation progress of patients with lower limb paralysis.

Artificial Intelligence-Assisted motion capture for medical applications: a comparative study between markerless and passive marker motion capture

We aimed to determine whether artificial intelligence (AI)-assisted markerless motion capture software is useful in the clinical medicine and rehabilitation fields. Currently, it is unclear whether the AI-assisted markerless method can be applied to individuals with lower limb dysfunction, such as those using an ankle foot orthosis or a crutch. However, as many patients with lower limb paralysis and foot orthosis users lose metatarsophalangeal (MP) joint flexion during the stance phase, it is necessary to estimate the accuracy of foot recognition under fixed MP joint motion. The hip, knee, and ankle joint angles during treadmill walking were determined using OpenPose (a markerless method) and the conventional passive marker motion capture method; the results from both methods were compared. We also examined whether an ankle foot orthosis and a crutch could influence the recognition ability of OpenPose. The hip and knee joint data obtained by the passive marker method (MAC3D), OpenPose, and manual video analysis using Kinovea software showed significant correlation. Compared with the ankle joint data obtained by OpenPose and Kinovea, which were strongly correlated, those obtained by MAC3D presented a weaker correlation. OpenPose can be an adequate substitute for conventional passive marker motion capture for both normal gait and abnormal gait with an orthosis or a crutch. Furthermore, OpenPose is applicable to patients with impaired MP joint motion. The use of OpenPose can reduce the complexity and cost associated with conventional passive marker motion capture without compromising recognition accuracy.

Activities With a Microprocessor-Controlled Leg Brace for Patients With Lower Limb Paralysis: A Series of Case Studies

Lower limb paralysis often leads to depreciation in mobility of the affected individuals. Computer-controlled leg brace systems open up new possibilities for these patients, by improving the safety of mobility tasks in everyday life, especially when walking on uneven terrain, inclined surfaces, steps and stairs. This article introduces such a system. To investigate the use of device functionalities in the patient's everyday environment, the knee joint of the brace was configured to store data of various sensors, measuring motion with a high temporal resolution over several weeks of home use. Results from a clinical trial including 8 patients with different pathologies show that the system was used by the patients for more than 10 hours per day on average, taking more than 2,100 steps per day. Maximum use time was more than 20.24 hours with 12,609 steps per day. An implemented yielding function to support walking down slopes or stairs was used by all patients. This function can also catch the user in case of stumbling, which on average happened 3 times per day. Seven out of eight patients reported improvements in quality and safety of many activities in daily life using the novel system, compared to their previous device.

Allergic Skin Reactions to Baclofen Pump: A Case Report

US was a 37-year old man who presented with generalized skin rashes of two years duration. He had a history of cervicothoracic (C6/T1) spine injury seven years earlier and for which he was managed conservatively at a secondary level hospital. He had Baclofen Pump inserted intrathecally in India four years following the spinal injury resulting in persistent spastic paralysis of both lower limbs. He was scheduled for intermittent Baclofen refill at India. Three months after the second drug refill, he developed generalized skin rashes. His vital signs were stable on presentation. He had wide-spread skin rashes. There was a bulge on the anterior abdominal wall on the right hypochondrial region due to the presence of the metallic implant. The dermatological review suggested foreign body reaction to exclude Acquired Ichthyosis was made. The patient had an explantation done and thereafter, showed remarkable improvement three months after the removal of the Intrathecal Baclofen Pump with healing and disappearance of the skin rash.

Analysis of the effect of percutaneous vertebroplasty combined with (125)I seed implantation in the treatment of spinal metastatic epidural spinal cord compression

Objective: To investigate the clinical efficacy of percutaneous vertebroplasty (PVP) combined with iodine-125 ((125)I) seed brachytherapy in the treatment of spinal metastatic epidural spinal cord compression (MESCC) and toassess the changes inthe grade of epidural spinal cord compression (ESCC) by magnetic resonance imaging (MRI). Methods: A total of 37 MESCC patients treated with PVP combined with (125)I seed brachytherapy in the interventional and vascular surgery department of Zhongda Hospital affiliated to Southeast University from January 2014 to June 2019 were retrospectively analyzed, including 23 cases of bilateral lower limbs paralysis. Total diseased vertebrae are 39 segments. Visual analogue scale (VAS) and paralysis of lower extremities were evaluated regularly before and after treatment, and VAS values at different follow-up time points were compared. At the same time, MRI was used to evaluate the changes of ESCC grade in the spinal canal and calculate the local lesion efficiency after operation. The postoperative local lesion efficiency at different follow-up times was compared. Results: PVP combined with (125)I seed implantation in all diseased vertebral bodies was successful. The average injection volume of polymethylmethacrylate (PMMA) was (3.2±1.3) ml/segment, the average number of (125)I seed implanted was (25.0±8.6) seeds/segment and the average radiation dose was (15.0±5.1) mCi/segment. The VAS before operation was 8.5, and postoperative VAS were respectively 3.6±1.3, 3.8±1.5, 3.4±1.4, 5.5±1.0, 5.9±1.4 at 5 days, 1 month, 3 months, 6 months, and 1 year after operation. The differences between all follow-up time points and preoperative VAS values were statistically significant (all P<0.001). Compared with 5 days, 1 month and 3 months after operation, VAS increased significantly at 6 months and 1 year after operation, and the difference was statistically significant (all P<0.001); there was no significant difference between the VAS value at 6 months after operation and 1 year after operation (P=0.405). At a follow-up of 3 months, 22 of 23 patients with paralysis of bilateral lower limbs regained the functions of autonomous walking and voiding; the effective rates of MESCC local lesions evaluated by MRI at 1 month, 3 months, 6 months, and>1 year were 89.7%, 91.9%, 90.6%, and 94.7%, respectively, and there was no statistically significant differences among those follow-up time points (all P>0.05). Conclusions: PVP combined with (125)I seed brachytherapy in the treatment of MESCC has significant improvement in immediate pain relief and spinal cord function. After combined treatment, MRI showed that the tumors around the spinal cord regressed dramatically, which could considerably reduce the MESCC grade and remain stable for a long time.

Automatic Grading of Stroke Symptoms for Rapid Assessment Using Optimized Machine Learning and 4-Limb Kinematics: Clinical Validation Study.

BackgroundSubtle abnormal motor signs are indications of serious neurological diseases. Although neurological deficits require fast initiation of treatment in a restricted time, it is difficult for nonspecialists to detect and objectively assess the symptoms. In the clinical environment, diagnoses and decisions are based on clinical grading methods, including the National Institutes of Health Stroke Scale (NIHSS) score or the Medical Research Council (MRC) score, which have been used to measure motor weakness. Objective grading in various environments is necessitated for consistent agreement among patients, caregivers, paramedics, and medical staff to facilitate rapid diagnoses and dispatches to appropriate medical centers.ObjectiveIn this study, we aimed to develop an autonomous grading system for stroke patients. We investigated the feasibility of our new system to assess motor weakness and grade NIHSS and MRC scores of 4 limbs, similar to the clinical examinations performed by medical staff.MethodsWe implemented an automatic grading system composed of a measuring unit with wearable sensors and a grading unit with optimized machine learning. Inertial sensors were attached to measure subtle weaknesses caused by paralysis of upper and lower limbs. We collected 60 instances of data with kinematic features of motor disorders from neurological examination and demographic information of stroke patients with NIHSS 0 or 1 and MRC 7, 8, or 9 grades in a stroke unit. Training data with 240 instances were generated using a synthetic minority oversampling technique to complement the imbalanced number of data between classes and low number of training data. We trained 2 representative machine learning algorithms, an ensemble and a support vector machine (SVM), to implement auto-NIHSS and auto-MRC grading. The optimized algorithms performed a 5-fold cross-validation and were searched by Bayes optimization in 30 trials. The trained model was tested with the 60 original hold-out instances for performance evaluation in accuracy, sensitivity, specificity, and area under the receiver operating characteristics curve (AUC).ResultsThe proposed system can grade NIHSS scores with an accuracy of 83.3% and an AUC of 0.912 using an optimized ensemble algorithm, and it can grade with an accuracy of 80.0% and an AUC of 0.860 using an optimized SVM algorithm. The auto-MRC grading achieved an accuracy of 76.7% and a mean AUC of 0.870 in SVM classification and an accuracy of 78.3% and a mean AUC of 0.877 in ensemble classification.ConclusionsThe automatic grading system quantifies proximal weakness in real time and assesses symptoms through automatic grading. The pilot outcomes demonstrated the feasibility of remote monitoring of motor weakness caused by stroke. The system can facilitate consistent grading with instant assessment and expedite dispatches to appropriate hospitals and treatment initiation by sharing auto-MRC and auto-NIHSS scores between prehospital and hospital responses as an objective observation.

Man with trauma following motorcycle crash.

A 56-year-old male presented to the emergency department (ED) following a frontal impact motorcycle accident. The patient was pale with persistent hypotension, tachypnea, and tachycardia along with bilateral lower limbs paralysis and a complete loss of sphincter functions. Patient was intubated, and transesophageal echocardiography performed by attending emergency physician at ED critical care bayshowed the transverse and longitudinal view of the descending aorta with hypoechoic, well-defined, crescent-shaped thickening of anterior aortic wall suggestive of intramural hematoma (Figures 1, 2; Supporting Information Videos S1 and S2). Computed tomography (CT) showed fracture T11 vertebra, intramural hematoma, and peri-aortic hematoma along the arch of the aorta extending down to upper abdominal aorta at the level of T12 (Figure 3). Traumatic thoracolumbar spine fracture with a concomitant blunt aortic injury is uncommon (1.4%) but potentially fatal.1 Most fractures associated with blunt traumatic aortic injury occurred at the level of T11–L2 vertebra (62%).1 ED transesophageal echocardiography is a potential new imaging adjunct in resuscitation.2-4 Even though the surface ultrasound has become an important bedside imaging tool in initial management of trauma patients in ED, its limitations include poor evaluation of vascular pathologies (ie, BTAI).5 The role of ED transesophageal echocardiography for the early detection of BTAI in hemodynamically unstable trauma patient was reported by Osman et al.6 The patient was managed conservatively and was discharged from spinal intensive care unit after day 10. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.