Permanent Neurological Sequelae Research Articles

An Overview of Japanese Encephalitis

INTRODUCTIONJapanese encephalitis virus (JEV) is a flavivirus, is the main cause viral encephalitis, endemic in South-East Asia, and Western Pacific regions and has become a major public health problem worldwide. JEV is transmitted to humans through the bite of an infected mosquito, mainly Culex tritaeniorhynchus that breeds in flooded rice fields, marshes, standing water around planted fields. Reservoir hosts are Adreid birds (herons and egrets), and pigs serve as amplifier hosts. Though infections are usually asymptomatic, the symptomatic Japanese encephalitis has a case fatality rate as high as 30%. Permanent neurologic or psychiatric sequelae can occur in 30-50% of those with encephalitis. There is no antiviral drug available. Treatment is mainly supportive and symptomatic. Safe and effective vaccines are available to prevent Japanese encephalitis. This article reviews recent advancements in diagnostic methods, prophylactics as well as therapeutic options and challenges to combat this zoonotic emerging and remerging viral encephalitis.

A rare case of spontaneous spinal epidural hematoma with spontaneous resolution

Spontaneous spinal epidural hematoma (SSEH) is an uncommon cause of acute spinal cord compression. It is a neurological emergency that requires urgent imaging and appropriate treatment to prevent permanent neurological sequelae. Here, we present the case of a 30-year-old male with no known comorbidities who presented to the emergency department with a history of sudden onset of upper backache and chest discomfort followed by bilateral lower limb weakness. On examination, the blood pressure was 220/120 mmHg, and neurological examination showed decreased tone and power of 2/5 in bilateral lower limbs. In view of the initial chest discomfort, a cardiac evaluation was done, which was normal, followed by magnetic resonance imaging of the whole spine, which showed a lesion in the anterior epidural space suggestive of hematoma, causing spinal cord compression. A final diagnosis was C6-T2 dorsal SSEH secondary to a hypertensive emergency.

Characteristics and associations of ocular and non-ocular manifestations of shaken baby syndrome.

Shaken baby syndrome (SBS), a subset of abusive head trauma, results from non-accidental, violent head shaking. Most survivors suffer permanent neurological sequelae. Accurate diagnosis is imperative and remains challenging. The purpose of this study is to describe ocular injuries and associated neurotrauma in suspected SBS. We retrospectively surveyed the National Trauma Data Bank 2008-2014 for patients ≤3years old admitted for suspected SBS. Statistical analysis was performed with SPSS software. Significance was set at p < 0.05. Three hundred forty-seven (13.9%) of 2495 patients who were ≤ 3years old were admitted with abusive head trauma and ocular injuries which resulted from suspected SBS. Most were < 1year old (87.9%) and male (54.2%). Common eye injuries were retinal hemorrhages (30.5%), eye/adnexa contusion (14.7%), and retinal edema (10.7%). Common neurotrauma were subdural (75.5%), subarachnoid (23.9%), and intracerebral hemorrhage (ICH) (10.4%). Mean (SD) Injury Severity Score was severe, 20.2 (8.2), and Glasgow Coma Score was moderate, 9.2 (12.8). The mortality rate was 16.7%. Retinal hemorrhages were not significantly associated with one type of neurotrauma over others. Ocular/adnexa contusion (OR 4.06; p < 0.001) and commotio retinae/Berlin's edema (OR 5.27; p < 0.001) had the greatest association with ICH than other neurotrauma. Optic neuropathy (OR 21.33; p < 0.001) and ICH (OR 3.34; p < 0.001) had the highest associated with mortality. Our study supports previous studies showing that retinal and subdural hemorrhages were the most common ocular injury and neurotrauma in SBS, respectively. However, we did not find a significant propensity for their concurrence. Commotio retinae/Berlin's edema was significantly associated with both intracerebral and subdural hemorrhages.

Natural products and derivatives as Japanese encephalitis virus antivirals.

Japanese encephalitis virus (JEV) causes acute Japanese encephalitis (JE) in humans and reproductive disorders in pigs. There are ~68 000 cases of JE worldwide each year, with ~13 600-20 400 deaths. JE infections have a fatality rate of one-third, and half of the survivors experience permanent neurological sequelae. The disease is prevalent throughout the Asia-Pacific region and has the potential to spread globally. JEV poses a serious threat to human life and health, and vaccination is currently the only strategy for long-term sustainable protection against JEV infection. However, licensed JEV vaccines are not effective against all strains of JEV. To date, there are no drugs approved for clinical use, and the development of anti-JEV drugs is urgently needed. Natural products are characterized by a wide range of sources, unique structures, and low prices, and this paper provides an overview of the research and development of anti-JEV bioactive natural products.

Diagnostic Accuracy of Cerebrospinal Fluid Procalcitonin and Serum Procalcitonin in Adult Patients with Bacterial Meningitis: A Cross-sectional Study

Introduction: Bacterial Meningitis (BM) is a serious health problem worldwide with high mortality and permanent longterm neurological sequelae. Cerebrospinal Fluid (CSF) analysis is the cornerstone for diagnosing BM, but the lack of specificity creates a difficult clinical scenario for initiating proper treatment. Empiric antibiotic use in patients with suspected meningitis at primary care settings decreases the yield of CSF culture and alters CSF cytological and biochemical findings, making it further difficult to diagnose BM. To overcome this difficulty, there is a need for other biochemical markers with higher sensitivity and specificity. Aim: To determine the diagnostic sensitivity and specificity of Procalcitonin (PCT) in serum and CSF in patients with BM and compare its diagnostic accuracy in both sample types. Materials and Methods: A cross-sectional study was conducted in the Department of Internal Medicine at a tertiary care centre in eastern India from September 2018 to August 2020. A total of 82 adult patients with meningitis were recruited as per the protocol, and CSF analysis was done along with estimation of PCT in serum and CSF. Receiver Operating Characteristics (ROC) curve analysis of serum and CSF PCT was used to determine sensitivity and specificity with a 95% confidence interval. Results: Out of the 82 patients recruited, 30 (36.6%) had BM. CSF PCT with a cut-off value of &gt;0.45 ng/mL had a sensitivity of 86.7% and specificity of 92.3%. The sensitivity of serum PCT with a cut-off value of &gt;0.6 ng/mL was 83.3%, and specificity was 86.5%. There was no statistically significant difference in sensitivity and specificity between CSF and serum PCT in patients with BM (p-value=0.7988). Conclusion: Both serum and CSF PCT were found to have high sensitivity and specificity as markers for diagnosing BM without any statistically significant difference between them.

Attenuated Chimeric GI/GIII Vaccine Candidate against Japanese Encephalitis Virus.

Japanese encephalitis (JE) is a very severe disease characterized by high fatality rates and the development of permanent behavioral, psychiatric, and neurological sequelae among survivors. Japanese encephalitis virus (JEV), a flavivirus, is responsible for JE. In Asia, Genotype I (GI) has emerged as the dominant strain, replacing Genotype III (GIII). However, no clinically approved drug is available to treat JEV infection, and currently available commercial vaccines derived from JEV GIII strains provide only partial protection against GI. Utilizing a reverse genetics system, this study attempted to produce a novel chimeric JEV strain with high efficacy against JEV GI. Accordingly, a GI/GIII intertypic recombinant strain, namely SA14-GI env, was generated by substituting the E region of the GIII SA14-14-2 strain with that of the GI strain, K05GS. The neurovirulence of the mutant virus was significantly reduced in mice. Analysis of the immunogenicity of the chimeric virus revealed that it induced neutralizing antibodies against JEV GI in mice, and the protective efficacy of SA14-GI env was higher than that of SA14-14-2. These findings suggest that SA14-GI env may be a safe and effective live-attenuated vaccine candidate against JEV GI.

The cervical branch-first technique in complex resternotomy

BackgroundBranch-first total aortic arch repair is a paradigm shift in the technical approach for uninterrupted neuroprotection during open aortic surgery. This technique is further modified to instigate hazardous sternal reentry in patients with hostile mediastinal anatomy at risk of aortic injury. MethodsIntraoperative preparation and the illustrated operative technique of the cervical branch-first technique are described. The accompanying case series narrates the experiences and outcomes of 4 patients who underwent successful complex reoperative aortic surgery utilizing this technique. ResultsThe indications for resternotomy included a sixth reoperation for recurrent mycotic aortic pseudoaneurysm, a third reoperation for extensive infective endocarditis, a reoperation for complete Bentall graft dehiscence with contained aortic rupture, and a third reoperation for residual type A dissection. All patients survived their proposed surgery. Two patients were operated on in an emergency setting. Two patients separated from cardiopulmonary bypass with extracorporeal support. None experienced permanent neurological sequelae, gut ischemia, peripheral arterial complications, or in-hospital mortality. One mortality due to decompensated heart failure was reported at 6 months postoperatively. ConclusionsThe cervical branch-first technique offers unparalleled advantage in neuroprotection from an early stage of complex reoperative aortic surgery. It provides an independent circuit for complete antegrade cerebral perfusion, irrespective of suspension to circulatory flows to the rest of the body during complex reentry into hostile chests. Our experience to date has demonstrated promising outcomes and further refinements will guide patient selection best suited for this technique.

Intoxication Camouflaged: Lesson Learnt. An Interesting Case of Lead Poisoning

Lead poisoning is a common occupational health hazard and may lead to permanent neurological sequelae or even death. However, there is an emerging trend of new forms of non-occupational lead poisoning which is challenging to diagnose. We report a case of a 40 y/o male who presented with chronic lead neurotoxicity occuring after consumption of over-thecounter ayurvedic medication. While exploring medication for its content, it was discovered that this abused drug had Papaver somniferum (opium) in the alarmingly high ratio of 12:1. A review of literature demonstrated that Lead is usually added to opium during its preparation either as an ingredient or as an adulterant to increase opium weight in its trading for profitability. Additionally, improvement in the neurological syndrome after chelation therapy with D-penicillamine further confirmed that Lead was the culprit responsible for this unusual presentation.

Hypoglycemia in Children: Major Endocrine-Metabolic Causes and Novel Therapeutic Perspectives.

Hypoglycemia is due to defects in the metabolic systems involved in the transition from the fed to the fasting state or in the hormone control of these systems. In children, hypoglycemia is considered a metabolic-endocrine emergency, because it may lead to brain injury, permanent neurological sequelae and, in rare cases, death. Symptoms are nonspecific, particularly in infants and young children. Diagnosis is based on laboratory investigations during a hypoglycemic event, but it may also require biochemical tests between episodes, dynamic endocrine tests and molecular genetics. This narrative review presents the age-related definitions of hypoglycemia, its pathophysiology and main causes, and discusses the current diagnostic and modern therapeutic approaches.

Late Postpartum Posterior Reversible Encephalopathy Syndrome: Case Series and Literature Review

Abstract Posterior reversible encephalopathy syndrome (PRES) is a reversible neurological entity characterized by seizures, headache, visual symptoms and other focal neurological findings. It is caused by wide variety of causes ultimately leading to vasogenic cerebral edema of occipital and parietal lobes of the brain. Prompt and early diagnosis of PRES is key in reducing the risk of permanent neurological sequelae. Occurrence of PRES during pregnancy or early postpartum period is well known. However, occurrence of PRES between 48 hours and one month postpartum in women who had normal pregnancy and delivery and no signs of preeclampsia is rare. In this case series we present three cases of PRES that occurred in young women during late postpartum period. All these three patients were normotensive during antenatal and early puerperal period but developed hypertension and vision loss in late puerperium. The prompt diagnosis and management of symptoms resulted in complete reversal of the symptoms with no permanent neurological deficit. Posterior reversible encephalopathy syndrome (PRES) is a reversible neurological entity characterized by the presence of white matter edema affecting the occipital and parietal lobes. The predominantly affected area of the cerebral cortex determines presentation in the patient. The reversibility of these symptoms is one of the hallmarks of the disease. Diffusion-weighted MRI is the gold standard in diagnosis of PRES as it helps to distinguish between vasogenic edema from cytotoxic edema. Prompt diagnosis and initiation of early treatment may lead to complete recovery with no residual neurological deficit.

Neonatal Meningitis-Causing Escherichia coli Induces Microglia Activation which Acts as a Double-Edged Sword in Bacterial Meningitis.

Bacterial meningitis is a devastating disease occurring worldwide, with up to half of survivors left with permanent neurological sequelae. Neonatal meningitis-causing Escherichia coli (NMEC) is the most common Gram-negative bacillary organism that causes meningitis, particularly during the neonatal period. Here, RNA-seq transcriptional profiles of microglia in response to NMEC infection show that microglia are activated to produce inflammatory factors. In addition, we found that the secretion of inflammatory factors is a double-edged sword that promotes polymorphonuclear neutrophil (PMN) recruitment to the brain to clear the pathogens but, at the same time, induces neuronal damage, which may be related to the neurological sequelae. New neuroprotective therapeutic strategies must be developed for the treatment of acute bacterial meningitis. We found that transforming growth factor-β (TGF-β) may be a strong candidate in the treatment of acute bacterial meningitis, as it shows a therapeutic effect on bacterial-meningitis-induced brain damage. Prevention of disease and early initiation of the appropriate treatment in patients with suspected or proven bacterial meningitis are the key factors in reducing morbidity and mortality. Novel antibiotic and adjuvant treatment strategies must be developed, and the main goal for new therapies will be dampening the inflammatory response. Based on this view, our findings may help develop novel strategies for bacterial meningitis treatment.

A Modified Technique for Interventional MRI-Guided Deep Brain Stimulation Using the ClearPoint System.

Deep brain stimulation (DBS) is increasingly performed using imaging-based techniques, which are rapidly evolving to minimize invasiveness and use limited resources efficiently. To describe a modified surgical technique for interventional MRI-guided stereotactic procedures using ClearPoint. A total of 160 consecutive DBS cases for Parkinson disease (48%), essential tremor (44%), dual essential tremor/Parkinson disease (3%), and dystonia (5%) were studied. Technique modifications included (1) preplanning the target/trajectory, (2) adoption of a smaller incision and new stereotactic frame, (3) changing the sequence of surgical steps, aiming to final target PRIOR to drilling, (4) reducing burr hole size, (5) minimizing dural opening, and (6) anchoring leads with a bio cement/plate combination in lieu of commercial devices. Demographic data, radial error, number of passes, and case time were prospectively collected while complications and clinical outcomes were retrospectively assessed. One hundred and forty seven DBS patients had 262 total leads placed. Average radial error was 0.41 mm bilaterally. Seventy nine leads had error <0.2 mm; 6 leads had error >1 mm. Pin-to-stylet insertion time, pin-to-frame removal time, and pin-to-room departure time were 2 hours 1 minute, 2 hours 48 minutes, and 3 hours 16 minutes, respectively, and were significantly shorter than those obtained with the original ClearPoint technique for our first 150 DBS cases ( P < .0001). Complications included infection with hardware removal (2.5%) and superficial hemorrhage without permanent neurological sequelae (1.9%). The modified ClearPoint technique maintains accuracy while reducing invasiveness and MRI time. This workflow can be expanded to other applications, including laser interstitial thermal therapy and gene delivery.

KRAMERS RULE AS A SCREENING TEST TO ASSESS NEONATAL HYPERBILIRUBINEMIA

Background: neonatal jaundice is a frequently encountered condition in the postnatal ward. If not treated properly, it can lead to permanent neurological sequelae. The gold standard investigation for diagnosis is total serum bilirubin (TSB)level. Transcutaneous bilirubinometers and visual assessment of cephalo-caudal progression of yellowish discoloration of neonatal skin by Kramers rule are commonly used non-invasive methods to predict jaundice. If correctly applied, these methods can help in minimising the number of blood samples to be drawn for TSB testing. Aims/Objectives:1. To assess the reliability of Kramers rule in predicting TSB in healthy neonates admitted in postnatal ward. 2. To assess theusefulness of Kramers rule in deciding which neonates require testing of TSB levels. Methods: This is a cross sectional study conducted on 100 healthy neonates admitted in the post-natal ward of a tertiary care hospital. Data was collected in pre-designed case record sheets. Sensitivity and specificity of Kramers rule in correct prediction of serum bilirubin was identified by using true and false outcomes. Results:The mean age at which neonates were examined was at 72 hours of life. 41% of the neonates were male and 59% were female.79% of the total babies were born via normal vaginal delivery and 21% via caesarean section.The sensitivity of Kramers rule in predicting serum bilirubin levels was 83.33% with a specificity of 54.55% (P value 0.015). Conclusion: Kramers rule is a fairly reliable method for predicting serum bilirubin levels and can help in avoiding unnecessary blood testing in neonates, especially in resource limited settings where such facilities might not be available.

Maximal safe resection of diffuse lower grade gliomas primarily within central lobe using cortical/subcortical direct electrical stimulation under awake craniotomy.

Diffuse lower-grade glioma (DLGG) in the central lobe is a challenge for safe resection procedures. To improve the extent of resection and reduce the risk of postoperative neurological deficits, we performed an awake craniotomy with cortical-subcortical direct electrical stimulation (DES) mapping for patients with DLGG located primarily within the central lobe. We investigated the outcomes of cortical-subcortical brain mapping using DES in an awake craniotomy for central lobe DLGG resection. We performed a retrospective analysis of clinical data of a cohort of consecutively treated patients from February 2017 to August 2021 with diffuse lower-grade gliomas located primarily within the central lobe. All patients underwent awake craniotomy with DES for cortical and subcortical mapping of eloquent brain areas, neuronavigation, and/or ultrasound to identify tumor location. Tumors were removed according to functional boundaries. Maximum safe tumor resection was the surgical objective for all patients. Thirteen patients underwent 15 awake craniotomies with intraoperative mapping of eloquent cortices and subcortical fibers using DES. Maximum safe tumor resection was achieved according to functional boundaries in all patients. The pre-operative tumor volumes ranged from 4.3 cm3 to 137.3 cm3 (median 19.2 cm3). The mean extent of tumor resection was 94.6%, with eight cases (53.3%) achieving total resection, four (26.7%) subtotal and three (20.0%) partial. The mean tumor residue was 1.2 cm3. All patients experienced early postoperative neurological deficits or worsening conditions. Three patients (20.0%) experienced late postoperative neurological deficits at the 3-month follow-up, including one moderate and two mild neurological deficits. None of the patients experienced late onset severe neurological impairments post-operatively. Ten patients with 12 tumor resections (80.0%) had resumed activities of daily living at the 3-month follow-up. Among 14 patients with pre-operative epilepsy, 12 (85.7%) were seizure-free after treatment with antiepileptic drugs 7 days after surgery up to the last follow-up. DLGG located primarily in the central lobe deemed inoperable can be safely resected using awake craniotomy with intraoperative DES without severe permanent neurological sequelae. Patients experienced an improved quality of life in terms of seizure control.

Acute flaccid myelitis in Switzerland - association with enterovirus D68.

Poliomyelitis-like acute flaccid myelitis associated with enterovirus D68 (EV-D68) has emerged globally during the past decade. Here we describe the first documented case reported from Switzerland, and a second, suspected case occurring in temporal association. AFM occurs primarily in children, is usually heralded by a febrile, respiratory prodrome followed by acute-onset, usually asymmetrical, limb weakness with some predilection for the upper extremities, and respiratory muscle compromise in one third of reported cases. There is no specific therapy and the majority of cases result in permanent neurological sequelae. A comprehensive diagnostic workup and timely reporting to the health authorities are essential. Surveillance of respiratory and stool samples for EV-D68 and other neurotropic enteroviruses is in place in several European countries and warrants consideration in Switzerland. This could entail the extension of the poliomyelitis surveillance program of the Federal Office of Public Health by monitoring and enteroviral typing of respiratory samples from patients with acute flaccid paralysis.

Complete fracture-dislocation of the cervical spine without permanent neurological sequelae: case report

Background: Cervical spine injuries occur in up to 3% of all trauma patients. Fracture-dislocation of the lower cervical spine is typically present with severe spinal cord injury in which the body of one vertebra rests fully anterior to the next body. With this kind of injury, there are very few examples where there is no permanent neurological deficit, and those that do exist are extremely rare. Case Presentation: A 19-year-old Saudi male patient was presented by ambulance to the emergency department. He was a front-seat passenger in a vehicle involved in a road accident. The patient was unconscious, Glasgow Coma Scale (GCS) (8/15), and quadriparetic. He was intubated and put on a mechanical ventilator and vasopressor support for persistent hypotension. American Spinal Injury Association impairment scale was a grade A. Initial management and resuscitation was done according to Advanced trauma life support (ATLS) guidelines: cervical collar application, logrolling, analgesic therapy, vitals normalized, and general condition stabilized. Skull traction was performed on admission. The patient underwent anterior cervical open reduction + C6/7 pedicle screw, and lateral mass screw internal fixation was performed. Conclusion: We report a rare case of complete fracture dislocation of C5/C6 listhesis with bilateral facet lock, with C7 fracture, C7/T1 listhesis, and bilateral facet lock. The patient presented with quadriparesis and was successfully treated with posterior reduction and fusion. The mechanism of injury, which was thought to be flexion and compression, was deduced by the patient&amp;apos;s history and the results of physical and neuroimaging examinations.

The etiologies and management of spinal cord compression in childhood cancers: Are we aware of the emergency of cord compression?

The spinal cord compression causes irreversible long-term permanent neurological sequelae. This study aims to increase awareness of childhood cancers that cause cord compression by comparing histopathological diagnosis, treatments, and survival rates to the literature. Seventy-three patients (38 male, 35 female) with spinal cord compression, among 1085 patients diagnosed with solid tumors at Gazi University Department of Pediatric Oncology between 1991 and 2021 were retrospectively evaluated. The mean time between the onset of complaints and diagnosis was 27.5± 24.9 (2-150) days. The first three most common tumors that caused cord compression; were central nervous system tumors in 22 (30%), neuroblastoma in 17 (23%), and malignant germ cell tumors in 8 (10%) cases. Of the patients, 46 (63%) had compression due to extradural masses, and 27 (37%) patients had an intradural compression. The most common symptoms were pain in 60 (82%), weakness in 57 (78%), and pins and needles in 28 (38%) patients, respectively. The clinical physical neurological examination findings were motor deficit in 62 (84%), and deep tendon reflex changes in 54 patients (73.9%). Compression findings were detected in 58 (79.5%) patients at diagnosis, and in 15 (20.5%) of them during follow-up. The most common level of compression was seen in the thoracolumbar region in 19 (26%) cases. In 65 (89%) patients with cord compression, corticosteroids were given as anti-edema treatment. Surgical excision was performed in 39 (53%) patients. Spinal radiotherapy was given to 35 patients (48%) with radiosensitive tumors. Chemotherapy protocols were started in 52 (71.2%) cases according to their diagnoses. Complete neurological recovery was achieved in 33 (45%) patients. The 5-year overall survival rates for solid tumors with extradural compression and intradural compression were 62% and 22%, respectively (p=0.002). Neurological sequela-free recovery is possible with early diagnosis and urgent treatment. Spinal compression must be detected by detailed systemic and neurological examination and imaging methods. Patients should be rapidly transferred to pediatric oncology units after starting anti-edema treatment.

Opsoclonus Myoclonus Syndrome and Supraventricular Tachycardia in a Pediatric Patient: A Case Report and Literature Review

Objective NA. Background Opsoclonus myoclonus syndrome (OMS) is a rare movement disorder in children often associated with an underlying neuroblastoma. In other cases, it is believed that the tumor is occult or there is another immune-stimulating precipitating event. Diagnosis can be difficult, requiring 3 of 4 criteria: opsoclonus or ocular flutter, myoclonus or ataxia, behavioral or sleep disturbances, and neuroblastoma. Prompt treatment of OMS is crucial to preventing permanent neurologic sequelae. In order to better characterize the clinical profile of this syndrome and its associated conditions, we present a case report of a 9 month old male with OMAS without an associated neuroblastoma and with new onset supraventricular tachycardia (SVT) and review the associated literature. Design/Methods NA. Results A 9-month-old male with a past medical history of macrocephaly, hypotonia, and developmental delay presented with abnormal eye and body movements starting one month prior. Due to concern for OMS, the patient underwent an extensive initial workup including CT neck, chest, abdomen, and pelvis and VHA/HMA levels, which were all within normal limits. The patient's spinal fluid revealed no evidence of paraneoplastic, autoimmune, or infectious processes. Per neurology recommendations, the patient was started on IVIG and dexamethasone. After his first IVIG infusion, the patient's abnormal movements worsened, and his heart rate increased into the 300s. The IVIG was discontinued. However, the patient continued to have recurring bouts of SVT, which was eventually controlled with digoxin. After resuming treatment with IVIG and dexamethasone, the patient's opsoclonus myoclonus symptoms began to improve. All additional metabolic labs resulted normal and the patient was discharged. Conclusions Because OMS can cause permanent developmental delay, prompt recognition and treatment of this syndrome is necessary. This is a unique case of OMAS without neuroblastoma, associated with recurrent bouts of SVT. Recognizing rare complications of OMS is crucial to improving medical management of its sequelae.

Head Injuries in Rock Climbing: A Scoping Review.

Rock climbing was recognized as a sport at the 2020 Tokyo Olympics. Despite its increasing participation, there is no knowledge synthesis of head injuries (HIs), defined as any injury to the head, associated with climbing, making it challenging for clinicians to provide evidence-based care. Our aim was to synthesize HI literature within rock climbing and identify knowledge gaps. Six databases (Medline, Embase, Sports Medicine & Education Index, SPORTDiscus, CINAHL, and Cochrane) were searched. Two reviewers screened 345 studies and 31 studies were selected for data abstraction. We found the quality of individual studies mainly "fair" to "good." Both HI and traumatic brain injury (TBI) had inconsistent definitions and categorization. The HIs represented between 0 to 36% of reported climbing injuries. Between 11 to 100% of HIs were TBIs, defined as an HI with permanent or temporary neurological sequelae. The most common causes of HIs were outdoor falls and falling objects. Climbing-specific factors associated with the causes were infrequently examined in the literature. Data sources of safety practices were incomplete. Overall, there was a lack of literature examining HIs, mechanisms of injury, and safety practices associated with climbing. To improve the tracking of HIs in climbing, we suggest the use of consistent reporting standards and the creation of a climbing injury surveillance system.

Treatable Ataxias: How to Find the Needle in the Haystack?

Treatable ataxias are a group of ataxic disorders with specific treatments. These disorders include genetic and metabolic disorders, immune-mediated ataxic disorders, and ataxic disorders associated with infectious and parainfectious etiology, vascular causes, toxins and chemicals, and endocrinopathies. This review provides a comprehensive overview of different treatable ataxias. The major metabolic and genetic treatable ataxic disorders include ataxia with vitamin E deficiency, abetalipoproteinemia, cerebrotendinous xanthomatosis, Niemann-Pick disease type C, autosomal recessive cerebellar ataxia due to coenzyme Q10 deficiency, glucose transporter type 1 deficiency, and episodic ataxia type 2. The treatment of these disorders includes the replacement of deficient cofactors and vitamins, dietary modifications, and other specific treatments. Treatable ataxias with immune-mediated etiologies include gluten ataxia, anti-glutamic acid decarboxylase antibody-associated ataxia, steroid-responsive encephalopathy associated with autoimmune thyroiditis, Miller-Fisher syndrome, multiple sclerosis, and paraneoplastic cerebellar degeneration. Although dietary modification with a gluten-free diet is adequate in gluten ataxia, other autoimmune ataxias are managed by short-course steroids, plasma exchange, or immunomodulation. For autoimmune ataxias secondary to malignancy, treatment of tumor can reduce ataxic symptoms. Chronic alcohol consumption, antiepileptics, anticancer drugs, exposure to insecticides, heavy metals, and recreational drugs are potentially avoidable and treatable causes of ataxia. Infective and parainfectious causes of cerebellar ataxias include acute cerebellitis, postinfectious ataxia, Whipple’s disease, meningoencephalitis, and progressive multifocal leukoencephalopathy. These disorders are treated with steroids and antibiotics. Recognizing treatable disorders is of paramount importance when dealing with ataxias given that early treatment can prevent permanent neurological sequelae.