Presence Of Neurological Deficits Research Articles

Blunt Cerebrovascular Injury: Our Experience and Review of Current Practice

Abstract Background: Blunt cerebrovascular injury (BCVI) is an injury to the carotid or vertebral artery that is nonpenetrating and results from stretching or impingement of the vessel walls due to sudden head movement. Recent studies showed that the incidence of BCVI is around 1%–9%, with stroke being the most dreaded complication. Methodology: This retrospective study was conducted after approval by the medical research ethics committee at our tertiary care center, including all consecutive neck computed tomography angiography scans for blunt trauma patients from January 2017 to December 2020. The patient demographics, symptoms, and signs at presentation and imaging were reviewed through the electronic patient records for the presence of BCVI using the modified Denver scoring and Biffl criteria. Patients younger than 18 years, those with penetrating trauma, and patients with no head-and-neck scans were excluded from the study. The treatment and outcome of the positive cases were studied. Results: There were 871 patients with blunt trauma during the study. Of this number, 16 patients were identified with BCVI (1.83%). Most of the patients were male (75%), and the mean age of the cohort was 31 years (18–45 years). Among those with BCVI, five had carotid artery injuries (31%), and 11 had vertebral artery injuries (68.8%). BCVI Grades 2 and 4 were the most prevalent injuries. Ischemic infarction was seen in three patients (18%). Five patients (31.3%) with BCVI received antiplatelet therapy. None of the patients underwent endovascular or surgical treatment. Moreover, there was no BCVI-related mortality. There was a statistically significant between the Biffl grading, type of artery injury, and the presence of neurological deficit at the time of initial presentation, which both turned to be significant with a P = 0.017 and P = 0.049, respectively. Conclusion: BCVI is a serious injury with the potential for neurological complications. The artery involved and Biffl grading influence the presentation. Initiation of therapy with antithrombotic medications for stroke prevention is essential in all patients. The patients with positive findings need follow-up imaging, and an internationally recognized guideline is essential to manage this cohort.

Incidence of cervical spine injuries in paediatric patients and their outcome in tertiary care hospital

Objective: The incidence of mortality after cervical trauma in the pediatric population is very high. The purpose of this study was to determine the treatment given, morbidity and mortality of patients with cervical spine injuries, and their outcome after 6 months of management which includes both surgical and conservative treatment. Materials & Methods: A prospective study was conducted at Lady Reading Hospital, Peshawar with a total number of patients n = 187 included in our study. Patients were stratified according to their age, mortality, mechanism of injury (fall, motor vehicle accident, bicycle injuries, &sports-related injuries), level of cervical spine injury, presence of neurologic deficit, presence of bony injury (fractures, &dislocations), ligamentous injuries & SCIWORA. The primary outcome was the functional status at 6 months following treatment. Results: There were 78 females and 109 males. In comparison to the lower cervical spine (C3 – C7), which was involved in 86 patients (46%), the higher cervical spine level (C0 – C2) was involved in 101 patients (or 54%). The most frequent cause of cervical spine injuries in the older age range was a history of a fall, followed by a motor vehicle accident. Among the treatment groups, mortality was highest in patients who underwent surgery. Conclusion: Younger age groups, higher cervical spine levels, and mechanisms of injury such as high energy impact trauma were independent risk factors for increased mortality. Compared to incomplete neurological abnormalities, a complete neurological disability increases mortality.

A Child with a Large Posterior Mediastinal Mass with Intraspinal Extension—Perioperative Anesthetic Challenges and Importance of Postoperative Analgesia

AbstractA 4-year-old girl child with a large posterior mediastinal mass with intraspinal extension (T2–T5) presented with paraplegia and bowel and bladder dysfunctions. She was planned for T1 to T6 laminoplasty and excision of the intraspinal tumor, followed by thoracotomy and excision of the posterior mediastinal tumor. Neurogenic tumors are common posterior mediastinal masses in children. These children pose many anesthetic challenges because of their size, location, and invasiveness. Challenges include difficult intubation, ventilation due to compression of the tracheobronchial tree, hemodynamic fluctuations because of compression of vital structures, associated autonomic dysfunction, and intraoperative bleeding. Pediatric lung isolation for thoracotomy and excision, obtaining motor evoked potential response in a child with poor functional grade status, and selecting appropriate analgesia techniques in the presence of neurological deficits are some of the added challenges. Anesthetic management and the use of a continuous erector spinae plane block for postoperative analgesia are highlighted in this report.

SEOM-GEINO clinical guidelines for high-grade gliomas of adulthood (2022).

High-grade gliomas (HGG) are the most common primary brain malignancies and account for more than half of all malignant primary brain tumors. The new 2021 WHO classification divides adult HGG into four subtypes: grade 3 oligodendroglioma (1p/19 codeleted, IDH-mutant); grade 3 IDH-mutant astrocytoma; grade 4 IDH-mutant astrocytoma, and grade 4 IDH wild-type glioblastoma (GB). Radiotherapy (RT) and chemotherapy (CTX) are the current standard of care for patients with newly diagnosed HGG. Several clinically relevant molecular markers that assist in diagnosis and prognosis have recently been identified. The treatment for recurrent high-grade gliomas is not well defined and decision-making is usually based on prior strategies, as well as several clinical and radiological factors. Whereas the prognosis for GB is grim (5-year survival rate of 5-10%) outcomes for the other high-grade gliomas are typically better, depending on the molecular features of the tumor. The presence of neurological deficits and seizures can significantly impact quality of life.

Densitometric correlates of degenerative-dystrophic processes in cervical vertebrae of humans and domestic animals

The cervical spine is the most mobile region with high work activity which constantly receives a heavy load. This region is the least protected from external influences, especially in cases of degenerative-dystrophic changes. A comparative analysis of clinical-morphological and morphometric data in degenerative-dystrophic lesions of the cervical spine in humans and domestic animals with secondary anatomical and physiological abnormalities was performed . The examined contingent of people was of young and middle age (average age equal to 41.5 ± 5.2 years). The examined animals had a similar age range recalculated to human age. The pathological changes in spinal cord configuration were registered in 84.6% of examined humans (n = 65) in the form of angular kyphosis or straightened lordosis (with the analogous relative distribution). In terms of gender, with the exception of the frequency of angular kyphosis, probable differences in the formation of lordosis, which is straightened (2.1 times more often), the indicators were the same while the normal configuration of the spine was more often registered in men against the women (20.0% vs 12.5%). Cervical spine deformations in different breeds of dogs and cats (n = 75) were observed in 34.7% of cases (angular kyphosis – 38.5%; straightened lordosis – 61.5%). Preservation of normal configuration of the cervical spine was recorded more often in cats – 78.6%, and in small breeds of dogs – 78.5%. In large breeds of dogs, these indicators were probably changed: the norm remained only in 26.3%, and the deformations exceeded the corresponding indicators in cats and small breeds of dogs by 2.7 or more times. The significant differences were found in cases of straightened lordosis formation which was registered more often in women than in men. The incidence of angular kyphosis was comparable in patients of both sexes. Cervical spine deformations in different breeds of dogs and cats were observed in 26 animals (34.6% cases: angular kyphosis – 13.3%; straightened lordosis – 21.3%). The densitry of vertebral bodies in all groups decreased in the caudal direction of the cervical spine. The differences in humans reached 18.1%, being higher in women than in men. Animals had a similar density distribution. This index was minimal in cats (2.7%), in small-breed dogs it increased significantly (7.5%) and in large-breed dogs it reached 14.3%, i.e. 5 times (compared to cats) and 2 times higher (compared to small breed dogs). A comparative analysis between humans and animals indicates that the maximal discrepancies in the studied indexes were found in humans and relatively coincided with those in large breed dogs. The presence of neurological deficit with cervical spine pain syndrome with lordosis distortion and the provocation of spinal canal stenosis was found in 73.7% of large adult dogs. The revealed regularities of cervical spine degenerative-dystrophic changes indicate that animals, especially large breeds of dogs, can serve as a model for investigation of etiopathogenetic factors, clinical course, prognosis and other risks of the bone-cartilage apparatus degeneration with both stenosis and vertebrogenic myelopathy development at the cervical level in humans The obtained clinical and morphometric data from comparative analysis in humans and domestic animals will serve as the basis of methods of prevention of degeneration in the bone-cartilage apparatus and the premature aging of the body in humans.

First report of lumbar spinal epidural hematoma after pelvic ring fracture.

Spinal epidural hematoma is a rare condition that most commonly occurs as a complication of spinal surgery. For patients with neurological deficits, surgical decompression can generally provide good outcome. A 56-year-old, otherwise healthy, patient was admitted to the orthopedic emergency department with a pelvic ring fracture. Over the course of 4 days, a lumbar spinal epidural hematoma developed, with the patient complaining of pain radiating to the S1 dermatome and saddle paresthesia. The hematoma was surgically decompressed, and the patient had a complete recovery. To our knowledge, this is the first report of a spinal epidural hematoma after pelvic ring fracture. The etiology of spinal epidural hematoma is diverse, but it is most frequently observed after spinal surgery. It has rarely been observed after lumbar spinal fractures, nearly exclusively in patients with ankylosing spondylitis. Pelvic ring fracture might result in spinal epidural hematoma. The presence of neurological deficits after such fractures is an indication for lumbosacral MRI. Surgical decompression will generally resolve the neurological symptoms.

Resolution of a Focal Pruritic Rash Following Neurosurgical Decompression in an Adolescent With Chiari I and Syringomyelia

BackgroundChiari I malformation (Chiari I) is defined by the downward displacement of one or both cerebellar tonsils below the foramen magnum of the skull with crowding altering cerebrospinal fluid flow. It can be associated with the development of a fluid-filled cavity within the spinal cord, syringomyelia. Neurological deficits or symptoms can occur at the level of anatomic involvement of syringomyelia. Case PresentationA young man presented to dermatology clinic for evaluation of a pruritic rash. Recognizing a unique left “cape-like” distribution of neuropathic itch leading to prurigo nodularis, he was referred for further evaluation by neurology in the local emergency department. After additional history and neurological exam, a magnetic resonance imaging confirmed Chiari I with an associated syringobulbia and a syrinx extending to T10/11 of the spinal cord. Anteriorly the syrinx extended into the left parenchyma of his spinal cord involving the dorsal horn, a lesion explaining his neuropathic itch. The sensation of itch and rash resolved after posterior fossa craniectomy and C1 laminectomy with duraplasty. ConclusionNeuropathic itch, in addition to pain, can be a symptom of Chiari I with syringomyelia. Focal pruritus without an obvious cutaneous trigger should prompt providers to consider a central neurological pathology. While many patients with Chiari I are asymptomatic, the presence of neurological deficits and syringomyelia, are indications for neurosurgical evaluation.

Duration of neurological deficit and outcomes in the surgical treatment of spinal coccidioidomycosis.

Vertebral osteomyelitis is a rare complication of coccidioidomycosis infection. Surgical intervention is indicated when there is failure of medical management or presence of neurological deficit, epidural abscess, or spinal instability. The relationship between timing of surgical intervention and recovery of neurological function has not been previously described. The purpose of this study was to investigate if the duration of neurological deficits at presentation affects neurological recovery after surgical intervention. This was a retrospective study of all patients diagnosed with coccidioidomycosis involving the spine at a single tertiary care center between 2012 and 2021. Data collected included patient demographics, clinical presentation, radiographic information, and surgical intervention. The primary outcome was change in neurological examination after surgical intervention, quantified according to the American Spinal Injury Association Impairment Scale. The secondary outcome was the complication rate. Logistic regression was used to test if the duration of neurological deficits was associated with improvement in the neurological examination after surgery. Twenty-seven patients presented with spinal coccidioidomycosis between 2012 and 2021; 20 of these patients had vertebral involvement on spinal imaging with a median follow-up of 8.7 months (IQR 1.7-71.2 months). Of the 20 patients with vertebral involvement, 12 (60.0%) presented with a neurological deficit with a median duration of 20 days (range 1-61 days). Most patients presenting with neurological deficit (11/12, 91.7%) underwent surgical intervention. Nine (81.2%) of these 11 patients had an improved neurological examination after surgery and the other 2 had stable deficits. Seven patients had improved recovery sufficient to improve by 1 grade according to the AIS. The duration of neurological deficits on presentation was not significantly associated with neurological improvement after surgery (p = 0.49, Fisher's exact test). The duration of neurological deficits on presentation should not deter surgeons from operative intervention in cases of spinal coccidioidomycosis.

Liensinine ameliorates ischemia-reperfusion-induced brain injury by inhibiting autophagy via PI3K/AKT signaling.

The current study aimed to explore the role of autophagy in cerebral ischemia-reperfusion injuries (CIRI) and elucidate the efficacy of liensinine treatment. An in vitro ischemia-reperfusion (I/R) neuronal cell model was established and pretreated with liensinine or rapamycin (RAPA). Cell proliferation and survival were detected using a cell counting kit-8 (CCK-8) assay, while cell damage and apoptosis were detected using the lactate dehydrogenase (LDH) leakage rate and flow cytometry. Autophagy activity was detected using monodansylcadaverine (MDC) staining. Thereafter, I/R models were established in vivo in rats and the presence of neurological deficits was examined. Hematoxylin-eosin (HE) and triphenyl tetrazolium chloride (TTC) staining was used to detect pathological damage in brain tissue and the volume ratio of the cerebral infarction. The levels of PI3K/AKT pathway-related proteins and autophagy-related proteins (mTOR, LC3, P62, and TSC2) were detected using Western blot. The findings showed that liensinine treatment increased cell viability, decreased cell injury and apoptosis, and inhibited autophagy. The addition of RAPA to promote autophagy inhibited cell viability and enhanced cell injury and apoptosis. The I/R rats in the model group exhibited deficient neurological function, while those in the liensinine treatment group showed restoration of normal neural function and reduction of the necrotic area and infarct volume ratio in the brain tissue. Furthermore, liensinine treatment also inhibited the PI3K/Akt pathway activity and autophagy. However, addition of RAPA reversed the effects of liensinine treatment and aggravated brain tissue injury. Therefore, liensinine can play a neuroprotective role in CIRI by inhibiting autophagy through regulation of the PI3K/Akt pathway.

Risk factors for drug-resistant epilepsy (DRE) in children and a model to predict development of DRE

Purpose. This study was conducted to investigate possible risk factors that could increase the occurrence of drug-resistant epilepsy (DRE), in hopes that the results could be used to educate the patient and their caregivers as well as increase early detection efforts. Methods. Case control study was conducted at neurology outpatient pediatric RSDS between May to December 2022. Risk factor of DRE such as sex, age of onset, type of seizure, initial seizure frequencies, history of cranial hemorrhage, cerebral infection, febrile seizure, status epilepticus, neonatal seizure, neonatal asphyxia, family history of epilepsy, present of neurological deficit, electroencephalogram (EE) finding, and result of neuroimaging examination were obtained through anamnesis and clinical examination. Risk factors were analyzed with bivariate analysis and multivariate analysis. A model was generated to predict probabilities of DRE in children with epilepsy. Results. DRE was observed in 84/137 (54%) patients. Bivariate analysis showed age of onset <1 years old (OR 2.31, p = 0.016), initial seizure frequencies >5 times/day (OR 3.0, p = 0.011), neonatal seizure (OR 3, p = 0.034), presence of neurologic deficit (OR 3.1, p=0.002), and abnormality of EEG (OR 2.82, p = 0.013) are significantly associated with DRE. Logistic regression revealed that initial seizure frequencies > 5 times/day (OR=2.5; 95%CI 1.051 to 6.028; P=0.038), present of neurological deficit (OR=2.58; 95%CI 1.205 to 5.531; P=0.031), and EE abnormality (OR=2.84; 95%CI 1.170 6.914; P=0.021) were significantly correlated with DRE. Our model sensitivity was 75.3% and 55.76% to predict DRE (AUC = 0.704, p=0.000). Conclusion. Seizure onsets of >5 times, neurological deficits, and EEG abnormality were found to be associated with drug resistant epilepsy.

Anterior approach arthrodesis - ALIF with use of a titanium cage for treatment of postoperative spondylodiscitis after lumbar microdiscectomy

Introduction. Infectious spondylodiscitis has an incidence of 0.21-3.6%. The best intervention should be individualized, using antibiotics only or combining them with stabilizing surgeries. Case presentation. A 38-year-old man presented with lumbosciatalgia, severe pain and inability to ambulate. Magnetic resonance imaging (MRI) of the lumbar spine showed L5-S1 extruded disc herniation and the patient underwent endoscopic microdiscectomy with complete remission of symptoms. After two weeks, he reported severe low back pain and a return of difficulty to walk. Laboratory tests showed an increase in CRP and ESR. MRI showed signs of lumbar spondylodiscitis. The patient started on broad-spectrum intravenous antibiotic therapy. He evolved with improvement in laboratory parameters and maintenance of low back pain. Due to the failure of conservative treatment, anterior approach arthrodesis (ALIF) was chosen, with the complete improvement of the low back pain and the return of the ability to walk. Discussion. Postoperative spondylodiscitis’ frequency depends on the invasiveness of the operation and the type of surgery performed. The most likely source of infection is direct inoculation by virulent pathogens during surgery. A diagnosis delay of more than two months is considered a risk factor for generating adverse results. A Conservative approach is indicated for the patient who is neurologically intact and with minimal bone destruction. Surgical indications are the presence of neurological deficits, intraspinal abscesses, extensive bone destruction, and failure of conservative management. ALIF is supported in the literature because it allows wide exposure of the entire disc space through efficient access to the spine with the complete evacuation of the disc, avoiding dissection of perineural scar tissue and preserving the articular facets. Conclusion. Early diagnosis and treatment are crucial, although there is still no consensus about the best treatment approach. The use of a titanium cage with a bioglass graft had a good response in pain and infection control in our case.

Abstract Number ‐ 238: More Rapid Anticoagulation is Safe for Cerebral Sinus Thrombosis Patients and Shortens ICU Stays

Introduction Cerebral sinus thrombosis (CST) can often prove challenging to manage effectively. Anticoagulation is the accepted first‐line therapy for treatment, but heterogeneity exists among treatment protocols. Anecdotally, delays in achieving therapeutic anticoagulation seem to prolong treatment courses and may lead to worse outcomes. Furthermore, delays in identifying the subset of patients not responding to medical therapy may preclude some patients from endovascular therapy who would otherwise be candidates but miss the therapeutic window. However, justifiable safety concerns often limit the speed with which anticoagulation targets are sought. This study examines the impact of time needed to achieve a therapeutic response to anticoagulation on hospitalization and clinical outcomes among patients admitted with symptomatic CST. Methods Patients admitted with CST at a single academic medical center between January 2020 and June 2022 were identified. Those with CST related to trauma, tumor, sepsis, or COVID infection were excluded. Date of admission, demographic factors, clinical status including neurological examination, and anticoagulation regimen were noted. The duration required to reach the therapeutic anticoagulation goal, defined according to partial thromboplastin time or anti‐Xa levels, was noted by measuring the time from commencement of anticoagulation therapy and the first lab result within the therapeutic range. The primary outcome was independence at discharge, which was determined by modified Rankin scale (mRS). Additional outcomes were determined by measuring ICU admission duration and mRS at discharge, thirty days, and ninety days. These were calculated with linear correlation and the Wilcoxon rank sum test, respectively. Additionally, an a priori multivariable model was constructed with covariates of age, gender, presence of neurological deficits at presentation, and presence of intracranial hemorrhage. To this base model, the binary variable of achievement of anticoagulation goal within 48 hours was added. Results No significant relationship was noted between time to therapeutic anticoagulation and mRS at discharge (p = 0.099), thirty days (p = 0.784), or ninety days (p = 0.931). Time required to achieve therapeutic anticoagulation was positively correlated with duration of ICU admission (r2 = 0.148, p = 0.013). In the multivariable model, functional status at discharge was largely driven by the admission neurological examination (p = 0.014). Among patients with neurological deficits, 66.7% were functionally independent at discharge, whereas this occurred in 95.7% of patients with a normal neurological examination at admission. For the base multivariable model, the area under the receiver operator curve was 0.895. Addition of the 48‐hour anticoagulation goal achievement variable increased it to 0.923 (p = 0.196). In the adjusted model, an odds ratio of 3.80 was identified for achieving independence at discharge (p = 0.280). Conclusions In patients admitted with CST, longer times required to achieve therapeutic anticoagulation are associated with prolonged ICU stays. More aggressive anticoagulation demonstrated no deleterious effects, and achieving anticoagulation goal by 48 hours demonstrated a trend toward independence at discharge. Such aggressive anticoagulation regimens may have the added benefit of maintaining candidacy for endovascular treatments by faster identification of patients’ responses to medical management. This preliminary research is likely underpowered and warrants further investigation to identify optimal treatment strategies for CST.

Clinical Outcomes in High Risk WHO Grade II Glioma Patients Treated with Upfront TMZ-Based Chemoradiotherapy

<h3>Purpose/Objective(s)</h3> The RTOG 9802 study demonstrated improved survival with use of chemoradiotherapy (CRT) over radiotherapy (RT) alone for WHO Grade II gliomas (LGG). PCV chemotherapy, utilized in that trial, is less commonly used in the U.S. and is associated with significant toxicity. We analyze our retrospective dataset of predominantly temozolomide (TMZ)-based CRT in LGG patients who would have been eligible for RTOG 9802. <h3>Materials/Methods</h3> Retrospective review of LGG patients (2000–2017) in a single institution pathology database was performed. Patients with histologies that included oligodendroglioma (OD), astrocytoma (AC) or astrocytoma (OA) who received upfront RT +/- chemotherapy were included in the analysis. We identified 67 eligible patients during this interval. Characteristics including age>40, RTOG high-risk features (age≥40 at time of diagnosis OR lack of a gross total resection (GTR)), tumor size>6 cm, tumor crossing midline, pathology (n= 37 AC, 20 OD, or 9 OA), presence of neurologic deficit at diagnosis, and utilization of RT and chemotherapy were determined. The CRT cohort (n=40) consisted primarily of TMZ (n=36) administered concurrently with RT. 27 patients received RT alone. RT for both cohorts consisted of a median dose of 54 Gy (range 50.4 - 54 Gy). 65/67 patients had "high risk" LGG as defined by RTOG 9802 criteria. Kaplan Meier analysis was used to assess overall survival (OS) and progression free survival (PFS). <h3>Results</h3> 5-year PFS for patients receiving CRT was 64% vs. 44% in those receiving RT alone (log rank p=0.009). This PFS curve shows increased separation of curves after 2 years similar to what was seen in RTOG 9802. Difference in PFS due to chemotherapy was driven by AC histology (57% vs. 21% PFS at 5 years, log rank p=0.002) while OD/OA PFS was not statistically altered with the addition of chemotherapy (79% vs. 72% PFS at 5 years, p=0.21). 5-year OS for patients receiving CRT was 76% vs. 69% in those receiving RT alone (p=0.11), with the CRT arm not yet reaching median survival<b>.</b> Cox Proportional Hazards analysis revealed that patients with astrocytoma (HR=6.14, p=0.0034), neurological deficit at presentation (HR=2.37, p=0.023) and tumor>6 cm (HR=-2.69, p=0.03) had an increased risk of death. Cox Proportional Hazards analysis showed that use of upfront CRT (HR=0.4, p=0.009) was the only factor that decreased the risk of earlier progression. Patients with AC (HR=3.21, p-0.018) or neurological deficit at presentation (HR=2.49, p=0.01) had increased risk of progression. <h3>Conclusion</h3> Use of upfront predominantly TMZ-based CRT has a PFS benefit over RT alone in a population of WHO grade II gliomas. This benefit of upfront TMZ-based CRT, a regimen generally significantly less toxic than PCV and better tolerated, appears to extend beyond the "very high risk" cohort from RTOG 0424 to include the "high risk" group from RTOG 9802, indicating a potential role for TMZ in a larger subset of LGG patients than previously-thought. This benefit appears to be driven by AC histology.

Post-traumatic hydrocephalus may be associated with autologous cranioplasty failure, independent of ventriculoperitoneal shunt placement: a retrospective analysis

Purpose Decompressive craniectomy (DC) is a common procedure used for the treatment of intracranial hypertension. Once brain swelling has subsided, a cranioplasty is performed to restore cosmesis and protection to the brain. While using the patient’s autologous bone flap is often the first choice in cranioplasty, this procedure is frequently complicated by bone flap resorption and infection. This study seeks to identify predictors of autologous cranioplasty failure. Methods A retrospective analysis was conducted on patients who underwent decompressive craniectomy and autologous cranioplasty. Patient demographics and factors related to both surgeries and failure rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in autologous cranioplasty failure. Results In our cohort, 127 patients underwent autologous cranioplasty. Overall, 18 (14.2%) patients experienced autologous cranioplasty failure. Regression analysis identified development of post-traumatic hydrocephalus (PTH) following DC (OR: 3.26, p = 0.043), presence of neurological deficits following DC (OR: 4.88, p = 0.025), and reoperation prior to CP (OR 3.0, p = 0.049) as significant predictors of autologous cranioplasty failure. Of the 16 patients who developed PTH following DC, 9 received a VP shunt. The rate of flap failure was similar across the 9 PTH patients who received a shunt and the 7 PTH patients who did not receive a shunt (33% vs. 57% failure rate, respectively, p = 0.341). Conclusion Autologous cranioplasty is a reasonably successful procedure with a flap failure rate of 14.2%. We identified PTH, persistent neurological deficits, and reoperation prior to cranioplasty as significant predictors of autologous cranioplasty failure. Interestingly, the presence of VP shunt did not impact the odds of flap failure.

Dysmature patterns of newborn EEG recordings: Biological markers of transitory brain dysfunction or brain injury

To investigate the prognostic value of dysmature EEG patterns in term or near-term newborns. Neonates with dysmature patterns in their first neonatal EEG, assessed during a 6-year period from January 2010 to December 2015, were included in the study. Their outcomes at their follow-ups in June 2019 (at the age of 3 years or more) were assessed, and the presence of neurological deficits and/or epilepsy was noted. We identified 347 neonates with video-EEG recordings during the observed period, in which 10 neonates had dysmature patterns in their first EEG. Eight were born at term and two were born late preterms, born at the 35 and 36-week gestational age. The reasons for admission were HIE grade I in 2 patients, grade II in 6 neonates, and heart problems in 2 patients. The second EEG was recorded at different time intervals, in 7 infants between 1 and 6 weeks; three infants had second EEG much later and were excluded from the study. Six of seven infants showed normal background activity (BA), and five had sharp waves over different regions, all six had normal developmental outcomes. One child with dysrhythmic pattern in the second EEG was diagnosed with genetic encephalopathy, developed spastic cerebral palsy and died due to severe pneumonia at the age of 6 years. Dysmature patterns may reflect transitory brain dysfunctions. Neonatal EEG tests remain reliable and important diagnostic tool in the very first weeks of life, particularly due to the availability of sequential EEG recordings and interpretations.

The Emergence of Dry Needling in Stroke Rehabilitation

The management of stroke, acute revascularization and rehabilitation techniques have taken a giant leap in the current decade. The presence of neurological deficits, spasticity and pain are the common limiting factors in post-stroke patients. The various rehabilitation measures in stroke are focused on improving the trio. Spasticity, in a post-stroke patient, is disabling and can be managed using oral pharmacological agents, botulinum toxin, intrathecal baclofen. The use of needle therapy, dry needling, which was commonly used in the management of myofascial pain syndromes has emerged useful in the management of spasticity. Further recent evidence has shown it to be useful in the other dimensions of stroke rehabilitation. Dry Needling is a skilled intervention, that is performed by trained personnel using a filiform needle. It can be performed superficially or deep. The speculative mechanisms by which dry needling reduces spasticity include inducing stretch in the muscle and afferent modulation of the sensory information from the muscle. It improves blood flow and oxygenation, reduces pain through central and peripheral mechanisms. (1)&#x0D; The use of dry needling in neurology has evolved from its use in the management of myofascial pain to spasticity in spastic tetra paresis and stroke rehabilitation. In post-stroke patients, dry needling has been used in the management of post-stroke spasticity, balance, post-stroke pain. In the management of spasticity, dry needling using ‘pistoning technique’ in the lower limbs (gastrocnemius, tibialis posterior) and upper limbs (shoulder, elbow and wrist) revealed improved scores in modified modified Ashworth scale (MMAS) that translated to improved gait and range of upper limb motion respectively. The dry needling was performed for 1 minute in each muscle studied. However, the number of sessions varied from a single session to 8-week therapy between studies. In the management of balance, the dry needling of the involved tibialis posterior muscle improved the balance as measured by single-leg stance, balance component of Fugl-Meyer scale and dynamic posturography. The improvement in the above measures is also shown to improve the functional outcome of post-stroke patients in Barthel index, 10-metre walk test, timed up and go test. The dry needling is shown to reduce pain including post-stroke shoulder pain by reducing the pain threshold. The above effects of dry needling were also evident in ultrasound assessment of the intervened gastrocnemius muscle that showed improved muscle length, reduced mean muscle thickness and angle of pennation. (1-3)&#x0D; The dry needling has also been studied in post-stroke rehabilitation as a component of the multimodal approach. The use of dry needling in conjunction with electrical stimulation of the muscle is shown to produce persistent improvement in the tone of the muscle. The adverse events noted following the use of dry needling include post interventional muscle soreness, bleeding, bruise and pain during the intervention. Major side effects such as loss of consciousness are rare and hence dry needling serves as a safe therapeutic option in the rehabilitation of post-stroke patients. (1-3)&#x0D; Hence dry needling is a safe, cost-effective technique that can be used in the management of post-stroke spasticity, balance, pain that translates to improved functional outcomes. However, further evidence is required to establish the efficacy of this promising technique in the management of post-stroke rehabilitation.

Epidemiological Pattern of Traumatic Brain Injury in the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

BackgroundAlthough the incidence of traumatic brain injury (TBI) has decreased since the beginning of the coronavirus disease 2019 (COVID-19) pandemic and severe acute respiratory syndrome coronavirus 2 is still evolving, the number of TBI cases has still greatly increased in multiple countries. In the present systematic review and meta-analysis, we evaluated the epidemiological characteristics of patients with TBI before and during the COVID-19 pandemic.MethodsWe conducted a systematic literature search of original studies, short reports, and research letters from databases on studies that contained data about the severity, mortality, presence of neurological deficits, radiological diagnosis, cause of injury, and type of management of TBI during a specified period within the pandemic compared with before the pandemic.ResultsA total of 18,490 subjects from 13 studies were included in the present study. The results of the meta-analysis showed a higher TBI mortality rate during the COVID-19 pandemic in the low-to-middle income countries (odds ratio, 1.65; 95% confidence interval, 1.12–2.41; P < 0.05; I2 = 40.8%; P = 0.18). The proportion of subdural hemorrhage was decreased, and the proportion of subarachnoid hemorrhage was increased in low- to middle-income and high-income countries, respectively. The proportion of assaults as the cause of TBI had increased during the pandemic (odds ratio, 1.40; 95% confidence interval, 1.06–1.86; P = 0.02; I2 = 20.8%; P = 0.28). We did not find any significant differences in the incidence of surgical intervention for TBI during the pandemic.ConclusionsOur results have indicated that during the COVID-19 pandemic, the TBI mortality rate had increased in low- to middle-income countries. The rate of assault as the cause of TBI had also increased during the pandemic.

Rapid versus slow withdrawal of antiepileptic drugs.

The ideal objective of treating a person with epilepsy is to induce remission (free of seizures for some time) using antiepileptic drugs (AEDs) and withdraw the AEDs without causing seizure recurrence. Prolonged usage of AEDs may have long-term adverse effects. Hence, when a person with epilepsy is in remission, it is logical to attempt to discontinue the medication. The timing of withdrawal and the mode of withdrawal arise while contemplating withdrawal of AEDs. This review examines the evidence for the rate of withdrawal of AEDs (whether rapid or slow tapering) and its effect on seizure recurrence. This is an updated version of the Cochrane Review previously published in 2020. To quantify risk of seizure recurrence after rapid (tapering period of three months or less) or slow (tapering period of more than three months) discontinuation of antiepileptic drugs in adults and children with epilepsy who are in remission, and to assess which variables modify the risk of seizure recurrence. For the latest update, on 8 November 2021, we searched: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid), and SCOPUS. There were no language restrictions. CRS Web includes randomized or quasi-randomized, controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), CENTRAL, and the Specialized Registers of Cochrane Review Groups including Epilepsy. Randomized controlled trials that evaluated withdrawal of AEDs in a rapid or slow tapering after varying periods of seizure control in people with epilepsy. Two review authors independently assessed the trials for inclusion and extracted the data. The outcomes assessed included seizure freedom after one, two, or five years of AED withdrawal; time to recurrence of seizure following withdrawal; occurrence of status epilepticus; mortality; morbidity due to seizure, such as injuries, fractures, and aspiration pneumonia; and quality of life (assessed by validated scale). There are two included studies in this review. One study randomized 57 children with epilepsy with seizure freedom for at least two years to taper down the AED over one or six months. The study was not blinded and there were no details of randomization. Over the period of 54 months of follow-up, 20/30 participants in the one-month group remained seizure-free compared to 15/27 participants in the six-month group (no evidence of a difference). There was no information on time of seizure recurrence for each group to allow a comparison. The other study involved 149 children. There was a non-significant trend towards a lower risk of seizure recurrence after one year of AED withdrawal in participants allocated to slow tapering (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.58 to 1.01; P = 0.06; very low-certainty evidence). At the end of two years, 30 participants were seizure free in the rapid-tapering group and 29 participants in the slow-tapering group (RR 0.87, 95% CI 0.58 to 1.29; P = 0.48; very low-certainty evidence). At the end of five years, 10 participants were seizure free in the rapid-tapering group and six participants in the slow-tapering group (RR 1.40, 95% CI 0.54 to 3.65; P = 0.49; very low-certainty evidence). There were no data for the other outcomes. Due to the methodological heterogeneity and the difference in the duration of tapering, we did not perform a quantitative synthesis of these studies. Currently, one Italian trial is ongoing that is investigating if a slow or a rapid withdrawal schedule of AEDs influences return of seizures (relapse) in adults with focal or generalized epilepsy who have been seizure free for at least two years (no preliminary results available). In view of methodological deficiencies, and small sample size of the two included studies, we cannot draw any reliable conclusions regarding the optimal rate of tapering of AEDs. Using GRADE, we assessed the certainty of the evidence as very low for outcomes for which data were available. We judged both studies to be at an overall high risk of bias. Further studies are needed in adults and children to investigate the optimal rate of withdrawal of AEDs and to study the effects of variables such as seizure types, aetiology, intellectual disability, electroencephalography abnormalities, presence of neurological deficits, and other comorbidities on the rate of tapering.

Neurofibromatosis type 2-associated meningiomas: an international multicenter study of outcomes after Gamma Knife stereotactic radiosurgery.

The management of neurofibromatosis type 2 (NF2)-associated meningiomas is challenging. The role of Gamma Knife radiosurgery (GKRS) in the treatment of these tumors remains to be fully defined. In this study, the authors aimed to examine the role of GKRS in the treatment of NF2-associated meningiomas and to evaluate the outcomes and complications after treatment. Seven international medical centers contributed data for this retrospective cohort. Tumor progression was defined as a ≥ 20% increase from the baseline value. The clinical features, treatment details, outcomes, and complications were studied. The median follow-up was 8.5 years (range 0.6-25.5 years) from the time of initial GKRS. Shared frailty Cox regression was used for analysis. A total of 204 meningiomas in 39 patients treated with GKRS were analyzed. Cox regression analysis showed that increasing the maximum dose (p = 0.02; HR 12.2, 95% CI 1.287-116.7) and a lower number of meningiomas at presentation (p = 0.03; HR 0.9, 95% CI 0.821-0.990) were predictive of better tumor control in both univariable and multivariable settings. Age at onset, sex, margin dose, location, and presence of neurological deficit were not predictive of tumor progression. The cumulative 10-year progression-free survival was 94.8%. Radiation-induced adverse effects were noted in 4 patients (10%); these were transient and managed medically. No post-GKRS malignant transformation was noted in 287 person-years of follow-up. GKRS achieved effective tumor control with a low and generally acceptable rate of complications in NF2-associated meningiomas. There did not appear to be an appreciable risk of post-GKRS-induced malignancy in patients with NF2-treated meningiomas.

Return to play in children with shunted hydrocephalus.

The objective of this study was to assess the relevance of shunted hydrocephalus in regard to participation by young patients in physical education (PE) classes. Students diagnosed with this condition are very often restricted in PE classes owing to the lack of official and well-defined guidelines. However, the medical literature suggests that there is no relationship between the disease and risk of sport-related injuries. In this study, the authors intended to evaluate not only the accuracy of this statement, but also to explore the factors that delay or foreclose return to exercise. The analysis was conducted on patients aged < 18 years with a diagnosis of shunt-treated hydrocephalus who received follow-up for a minimum of 1 year. Collected medical data were examined for factors limiting participation in PE at school. Indicators of both sport-related injuries and conditions acceptable for return to exercise were gathered during follow-up visits. In this study, 72.72% of patients attended sport activities in schools. The group based on return to PE class differed significantly in the occurrence of neurological deficits, as well as presence of comorbidities. In univariate analysis, the authors identified these parameters as risk factors limiting participation in PE. On the contrary, etiology of hydrocephalus, type of shunting device, number of shunt malfunctions, and presence of epilepsy did not significantly influence sport engagement. This study shows that many patients with shunt-treated hydrocephalus can safely participate in PE. Presence of neurological deficits before and after neurosurgical treatment, as well as presence of comorbidities, are factors that negatively impact the possibility of a patient returning to physical activity. Sport-related injuries do occur, but at a low incidence.