Predictors Of Symptom Development Research Articles

Loss of Consciousness and Righting Reflex Following Traumatic Brain Injury: Predictors of Post-Injury Symptom Development (A Narrative Review).

Identifying predictors for individuals vulnerable to the adverse effects of traumatic brain injury (TBI) remains an ongoing research pursuit. This is especially important for patients with mild TBI (mTBI), whose condition is often overlooked. TBI severity in humans is determined by several criteria, including the duration of loss of consciousness (LOC): LOC < 30 min for mTBI and LOC > 30 min for moderate-to-severe TBI. However, in experimental TBI models, there is no standard guideline for assessing the severity of TBI. One commonly used metric is the loss of righting reflex (LRR), a rodent analogue of LOC. However, LRR is highly variable across studies and rodents, making strict numeric cutoffs difficult to define. Instead, LRR may best be used as predictor of symptom development and severity. This review summarizes the current knowledge on the associations between LOC and outcomes after mTBI in humans and between LRR and outcomes after experimental TBI in rodents. In clinical literature, LOC following mTBI is associated with various adverse outcome measures, such as cognitive and memory deficits; psychiatric disorders; physical symptoms; and brain abnormalities associated with the aforementioned impairments. In preclinical studies, longer LRR following TBI is associated with greater motor and sensorimotor impairments; cognitive and memory impairments; peripheral and neuropathology; and physiologic abnormalities. Because of the similarities in associations, LRR in experimental TBI models may serve as a useful proxy for LOC to contribute to the ongoing development of evidence-based personalized treatment strategies for patients sustaining head trauma. Analysis of highly symptomatic rodents may shed light on the biological underpinnings of symptom development after rodent TBI, which may translate to therapeutic targets for mTBI in humans.

A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression.

Study Design:Guideline development.Objectives:The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate, and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy.Methods:Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness, and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing, and predictors of symptom development. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the management of degenerative cervical myelopathy (DCM).Results:Our recommendations were as follows: (1) “We recommend surgical intervention for patients with moderate and severe DCM.” (2) “We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial nonoperative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve.” (3) “We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically.” (4) “Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or nonoperative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above.”Conclusions:These guidelines will promote standardization of care for patients with DCM, decrease the heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

The timing of surgery of antenatally diagnosed choledochal malformations: A descriptive analysis of a 26-year nationwide cohort

IntroductionCholedochal malformations (CMs) are increasingly diagnosed antenatally. There is a dilemma between early surgery to prevent CM-related symptoms and postponing surgery to reduce complications. We aimed to identify the optimal timing of surgery in asymptomatic neonates with antenatally diagnosed CM and to identify predictors for development of symptoms. MethodsUsing the Netherlands Study group on CHoledochal Cyst/malformation (NeSCHoc) we retrospectively collected demographic, biochemical and surgical data from all Dutch patients with an antenatally detected CM. ResultsBetween 1989 and 2014, antenatally suspected CM was confirmed in 17 patients at a median age of 10days (1day–2months). Four patients developed symptoms directly after birth (24%). Thirteen patients (76%) remained asymptomatic. Two of these progressed to symptoms before surgical intervention at 0.7 and 2.1months resp. Postoperatively, four patients developed short-term complications and three developed long-term complications. Patients <5.6kg (the series median) showed more short-term complications (66%) when compared to patients >5.6kg (0%, p=0.02). ConclusionWhen not symptomatic within the first days of life, the majority of children with antenatally detected CM remains asymptomatic. Surgery might safely be delayed to the age of 6months or a weight of 6kg. Postponing surgery in the clinically and biochemical asymptomatic patient might decrease the complication rate. Levels of evidenceLevel III.

Abstract 212: Factors Associated with Symptom Development in Asymptomatic Carotid Artery Stenosis: Multimodal Carotid and Perfusion Imaging Study

Background: The predictors of symptom development in asymptomatic carotid stenosis are still unclear. We sought to identify factors associated with symptom development in asymptomatic carotid stenosis using multimodal imaging technique. Methods: We retrospectively collected patients who had carotid artery revascularization procedures (carotid endarterectomy [CEA] or carotid artery stenting [CAS]) from April 2007 to May 2013. Patients who had event of cerebral ischemic stroke during 6 months before CEA or CAS were categorized as a symptomatic carotid stenosis. Results from carotid Duplex sonography, CT angiography, brain MRI and MRA, perfusion-weighted MRI (PWI), and demographic profiles were compared. Multivariate logistic regression analysis was performed to identify factors associated with symptom carotid stenosis. Results: A total of 684 patients (asymptomatic 58%, symptomatic 42%) with carotid stenosis more than 50% were included. The presence of ischemic heart diseases, peripheral artery occlusive disease and use of statin were higher in the asymptomatic carotid stenosis. On Duplex scan, ulceration, echolucent plaque, and heterogeneous components of plaque were more frequent in symptomatic carotid stenosis. Angiographic data showed the length of plaque was longer in symptomatic carotid stenosis. Presence of deep white matter hyperintensity, FLAIR vessel sign and GRE vessel sign were more frequently observed in symptomatic carotid stenosis. Patients with symptomatic carotid stenosis had increased cerebral blood flow, cerebral blood volume (CBV), and delayed time to peak when compared to the asymptomatic stenosis. Multivariate analysis revealed length of plaque (&gt;20mm), deep white matter hyperintensity and increased CBV were associated with symptomatic carotid stenosis (Odd ratio [OR]=2.339, 95% confidence interval [CI] 1.312-4.169, P=0.004; OR=2.315, 95% CI 1.160-4.619, P=0.017; OR=2.242, 95% CI 1.127-4.463, P=0.021, respectively). Conclusion: Plaque burden, deep white matter hyperintensity, and increased CBV were independent predictors of symptom development in carotid stenosis. Multimodal imaging may be useful to identify high risk patients of ischemic stroke among asymptomatic carotid stenosis.