Residual Deficits Research Articles

High and Persistent Anti-GM1 Antibody Titers Are Associated With Poor Clinical Recovery in Guillain-Barré Syndrome.

Guillain-Barré syndrome (GBS) is an acute immune-mediated polyradiculoneuropathy that may follow a preceding infection inducing a cross-reactive antibody response to glycosphingolipids in peripheral nerves. The immune response in GBS is considered to be short lasting, explaining its monophasic clinical course. However, the disease course varies between patients, and residual deficits frequently occur. The duration of the antibody response has not been defined extensively in GBS, and the persistence of these antibodies may impair clinical recovery. The aim of this study was to determine the titer course of serum antibody titers to the ganglioside GM1 in relation to clinical course and outcome in patients with GBS. Acute-phase sera from patients with GBS included in previous therapeutic trials were screened for anti-GM1 IgG and IgM antibodies in ELISA. Anti-GM1 antibody titers were determined in sera collected at entry and during a 6-month follow-up. Clinical course and outcomes were compared between groups based on the titer course. Anti-GM1 antibodies were detected in 78 (20.7%) of 377 included patients. The anti-GM1 IgG and IgM antibody titer course was highly variable between patients. A subset of anti-GM1-positive patients had persistent anti-GM1 antibodies at 3 months (n = 27/43 [62.8%]) and 6 months (n = 19/41 [46.3%]). Patients with a high anti-GM1 IgG and IgM titer at entry recovered more slowly and less complete than anti-GM1-negative patients (IgG: p = 0.015, IgM: p = 0.03). High vs low IgG titers were independently associated with poor outcome after correcting for known prognostic factors (p = 0.046). Among patients with a high anti-GM1 IgG titer at entry, a slow titer decline was associated with poor outcome at 4 weeks (p = 0.003) and 6 months (p = 0.032). Persistent high IgG titers at 3 and 6 months were associated with poor outcome at 6 months (3 months: p = 0.022, 6 months: p = 0.004). High anti-GM1 IgG and IgM antibody titers at entry and persistent high anti-GM1 IgG antibody titers are associated with poor outcome in patients with GBS. Antibody persistency indicates ongoing antibody production long after the acute disease state in GBS. Further research is required to determine whether antibody persistency interferes with nerve recovery and is a target for treatments.

Minced muscle autografting improves bone healing but not muscle function in a porcine composite injury model.

Composite tissue injuries (CTIs) in extremities include segmental bone defects (SBDs) and volumetric muscle loss. The objective of this study was to determine if skeletal muscle autografting with minced muscle grafts (MMGs) could improve healing in an SBD and improve muscle function in a porcine CTI model that includes an SBD and adjacent volumetric muscle loss injury. Adult Yucatan Minipigs were stratified into three groups including specimens with an isolated SBD, an SBD with volumetric muscle loss (CTI), and an SBD with volumetric muscle loss treated with MMG (CTI + MMG). Bone healing was quantified with serial x-rays and postmortem computed tomography scanning. Muscle function was quantified with a custom in vivo force transducer. Muscle tissue content was determined by biochemical analyses and histology. Anterior cortex-modified Radiographic Union Score for Tibia fractures (mRUSTs) decreased from 2.7 to 1.9 (p = 0.003) in CTI versus SBD animals. MMG improved anterior mRUST scores to 2.5 in CTI + MMG specimens (p = 0.030 compared to CTI specimens) and overall mRUST scores increased from 9.4 in CTI specimens to 11.1 in CTI + MMG specimens (p = 0.049). Residual strength deficits at euthanasia were 42% in SBD (p < 0.001), 44% in CTI (p < 0.001), and 48% in CTI + MMG (p < 0.001) compared to preoperative values. There were no differences in strength deficits between the three groups. Biochemical and histologic analyses demonstrated scattered differences between the three groups compared to contralateral muscle. MMG improved bone healing. However, the primary cause of muscle dysfunction and biochemical changes was the presence of an SBD. Clinical significance: Early mitigation of SBDs may be necessary to prevent muscle damage and weakness in patients sustaining composite extremity trauma.

Incidental damage of obturator nerve during laparoscopic pelvic lymphadenectomy in endometrial cancer – Demonstration of a successful repairing procedure

ObjectiveIn order to highlight the importance of intraoperative complications and their management, we demonstrate a video of an iatrogenic left obturator nerve lesion during a pelvic lymphadenectomy for endometrial cancer staging. The repair was promptly performed using an intracorporeal laparoscopic suture for an end-to-end tension-free nerve anastomosis. DesignStepwise demonstration of the technique with narrated video footage. SettingA 70-year-old woman with a stage IB grade I endometrial adenocarcinoma was submitted to a surgical laparoscopic staging with total hysterectomy(TH), bilateral adnexectomy(BA), and bilateral pelvic and lomboaortic lymphadenectomy. After an uneventful retroperitoneal lomboaortic lymphadenectomy, the left paravesical space was dissected until the obturator fossae and a left pelvic lymphadenectomy followed, during which the left obturator nerve was accidentally transected with LigaSure™. InterventionsA careful inspection revealed an almost complete transection (80%) of the nerve, with both proximal and distal cut ends identifiable and no fraying of the edges. The thickness of the non-sectioned nervous portion was less than 3 mm, but a tension-free reattachment of both edges seemed manageable. The edges were oriented towards each other and a single stitch suture was placed using a 5–0 prolene, providing an epineural end-to-end coaptation. To reinforce the suture, a Fibrin sealant Tissucol® was applied. The contralateral pelvic lymphadenectomy was then performed, followed by TH and BA. The pieces were removed through the vagina using an endobag. The patient was discharged on the second postoperative day. During the follow-up, there were no signs of diminished adductor function, and neither there was any other detectable residual neuropathy or neurologic deficit involving the left thigh. ConclusionIt is crucial to identify intraoperative complications and to develop abilities to manage them. This video proves that it is possible to repair a transected obturator nerve using laparoscopy, when performed by an experienced onco-gynecologist, with extremely good functional results.

A Case of Varicella-zoster Virus Meningitis without Rash Diagnosed by Multiplex PCR

A healthy, immunocompetent 15-year-old girl was admitted to our hospital with headache, fever, and loss of consciousness after vomiting. The vomiting and consciousness disturbance improved promptly without any specific treatment. While there was meningism, due to the persistent headache and fever, a CSF examination was performed on the fourth day of admission, which revealed lymphocytic pleocytosis, and varicella-zoster virus (VZV) DNA was detected by Multiplex PCR. The patient gave a history of having had chickenpox at 4 years of age. She received a 14-day course of intravenous acyclovir, and the treatment was switched to oral valacyclovir, given for another 3 days. She made a full recovery, with no residual neurologic deficit. The frequency of VZV meningitis in children is low, and there have been reports of a few cases without skin rash. It is possible that some cases diagnosed as cases of aseptic meningitis without skin rash may be cases of VZV meningitis. Multiplex PCR testing is considered as being an important tool for early diagnosis and appropriate treatment.

A Study on the Clinical Profiles of Patients With Cerebrovascular Accident (Stroke) in a Tertiary Care Hospital in Jharkhand.

Introduction Stroke is a devastating and disablingcerebrovascular disease with a significant amount of residual deficit. The prevalence of stroke is in a rising trend in India. Larger studies are needed for the evaluation of risk factors. Material and methods This cross-sectionalstudy aimed to assess the clinical profile of patients with stroke. The demographic details of the patients were taken, comorbidities were noted, and laboratory tests were done. Observation The most common age group who presented with stroke was 61-80 years, followed by 41-60 years, comprising 47% and 46%, respectively. Ischemic stroke was more common (60%) than hemorrhagic stroke (40%). Male patients were more than female patients. Alcohol, smoking, hypertension, diabetes, anemia, and proteinuria were present in the study group. Conclusion Regular evaluation of blood pressure, blood sugar, lipid profile, and proteinuria should be routinely done in patients with diabetes and hypertension who are more than 40 years old.

Risk of Lower Extremity Ligamentous Injury Following Concussion Diagnosis: A TriNetX Database Study.

Background Concussion is one of the most frequently reportedsports-related injuries in the United States; there is evidence that residual deficits in neurocognition may increase the risk of lower extremity musculoskeletal injury after concussion in high school, college, and professional athletes. The purpose of this study is to identify whether similar trends are identified in community-based populations. Methods The TriNetX Research Network database was queried for patients 10-60 years old who experienced an ambulatory or emergency visit from 2018-2020. Cohorts were defined by patients seen for concussion and patients seen for other reasons. These cohorts were then propensity score matched based on significant differences in demographics; after matching, each cohort included 97,708 patients. The propensity score-matched cohorts were then evaluated to identify patients who experienced subsequent lower extremity ligamentous injury within 12 months. Results Patients with a history of concussion were more likely to experience posterior cruciate ligament (PCL) sprain (0.04% vs. 0.02%, risk ratio (RR)=1.79, p=.039), medial collateral ligament (MCL) sprain (0.18% vs. 0.08%, RR=2.355, p<.001), lateral collateral ligament (LCL) sprain (0.05% vs. 0.02%, RR=2.202, p=.003) and ankle sprain (1.05% vs. 0.47%, RR=2.265, p<.001). Conclusion Patients diagnosed with concussion were more likely to experience a lower extremity ligamentous injury when compared with patients who did not have concussion. Patients should be counseled regarding this increased risk and additional neuromuscular evaluation and injury prevention education may be indicated following concussion diagnosis.

Cerebellar Mutism Syndrome After Posterior Fossa Tumor Surgery in Children—A Retrospective Single-Center Study

Cerebellar mutism syndrome (CMS) is a well-known complication following posterior fossa tumor surgery in pediatric patients. We evaluated the incidence of CMS in our institute and analyzed association with multiple risk factors, such as tumor entity, surgical approach, and hydrocephalus. All pediatric patients who received an intra-axial tumor resection in the posterior fossa between January 2010 and March 2021 were included for retrospective analysis. Various data points, including demographic, tumor-associated, clinical, radiological, surgery associated, complications and follow-up data were collected and statistically evaluated for association with CMS. 63 surgeries in 60 patients were included with a median age of 8 years. Pilocytic astrocytoma was mostly represented by 50%, followed by medulloblastoma in 28%, and ependymomas in 10%. Complete resection was achieved in 67% versus subtotal in 23%, and partial resection in 10%. Telovelar approach was the most used in 43 % compared to transvermian in 8%. 10 children (17%) developed CMS and showed marked improvement but with residual deficits. Significant risk factors were transvermian approach (p=0.03), vermian splitting whenever added to other approach (p=0.002), initial presentation with acute hydrocephalus (p=0.02), and remaining hydrocephalus after tumor surgery (p=0.004). Our CMS rate compares to those described in literature. Despite the limitations of our study as a retrospective one, we found CMS was not only associated with a transvermian approach, but also occurs after using a telovelar approach, however to a lesser extent. Acute hydrocephalus at initial presentation necessitating urgent management was significantly associated with higher incidence of CMS.

Abstract Number ‐ 232: Carotid Webs as an Under‐Reported Etiology of Acute Ischemic Stroke – Current Diagnostic Challenges

Introduction Carotid webs are anatomical variants in the internal carotid artery vasculature that predispose patients to stroke. As of now, optimal treatment has yet to be established given the lack of large, randomized trials. Part of this stems from the fact that carotid webs remain under‐recognized sources of ischemic stroke despite a high rate of reoccurrence. Herein, we aim to shed light on the diagnosis with our respective center’s experience as well as discuss diagnostic challenges associated with carotid webs. Methods We present a case of a 40‐year‐old male with no past medical history who presented to our center after having developed sudden onset left sided weakness and sensory loss, a left homonymous hemianopia, and dysarthria. Vessel imaging confirmed a right middle cerebral artery occlusion, specifically in the M2 segment, in the setting of a right carotid web. Results Once intracerebral hemorrhage was ruled out, tissue plasminogen activator was administered, with improvement in neurologic exam. Mechanical thrombectomy was thus deferred. Review of the MRI brain showed that in addition to an infarct in the right subinsular white matter region, there were scattered multifocal right hemispheric acute to early subacute infarcts raising concern for an underlying embolic etiology. While the right M2 occlusion looked like it had mainly resolved, a new focal non‐occlusive intraluminal thrombus was found in the right carotid bulb on CTA, MRA, and carotid ultrasound, just distal to a small transverse extraluminal carotid web (Figure 1). The decision was made to take the patient for right carotid stenting given that the carotid web served as a high‐risk lesion. A stent was placed in the right carotid artery with no complications, and the patient was continued on dual antiplatelet therapy. Upon being seen in outpatient clinic after discharge, patient had NIHSS score of 0, with no residual deficits, and was continued on DAPT and a statin for secondary stroke prevention. Conclusions Knowing that patients with carotid webs are at increased risk for stroke, recognition and accurate diagnosis of webs is crucial for appropriate treatment. Diagnostic challenges of carotid webs should be highlighted to prevent misdiagnosis. These include heightened awareness of the patient population that is most at risk, radiographic mimics, location of the lesion as a confounder, and rule out of other stroke etiologies. Prompt recognition of this high‐risk vascular lesion using multiple imaging modalities at different time points during the patient’s admission allowed for treatment of the underlying etiology of his stroke. By increasing awareness on the appropriate diagnostic approach for carotid webs, more information can be garnered to elucidate optimal treatment strategies.

Abstract Number ‐ 72: A Successful Emergent Endovascular Mechanical Thrombectomy in An Extensive Deep Cerebral Venous Sinus Thrombosis

Introduction Cerebral venous sinus thrombosis (CVST) is an uncommon variant of strokes, accounting for 0.5‐1% of all cases. Current guidelines recommend systemic anticoagulation as the first line therapy with endovascular approach reserved for those who fail to recanalize. We describe a 24‐year old female who presented with 3 days of headache and right sided weakness and was found to have extensive deep CVST with intracerebral hemorrhage and obstructive hydrocephalus. She underwent successful emergent intravenous thrombectomy with complete recanalization after clinical and radiological deterioration despite optimal systemic anticoagulation and bilateral external ventricular drains (EVDs). Methods The patient underwent thrombectomy under general anesthesia. Angiogram through the right radial artery was performed showing extensive thrombosis involving straight sinus, inferior sagittal sinus, vein of Galen and the internal cerebral vein. A right common femoral vein access was obtained and 80 cm Cook shuttle was placed and advanced to left internal jugular vein. Two passes mechanical thrombectomy using Y stent technique with the solitaire 6×40mm and Embotrap 6.5×45 mm stent retrievers and Zoom 008 with 071 aspiration catheters was performed with minimal recanalization of straight and inferior sinus. Attempted active aspiration and Power Pulse lytic thrombectomy through AngioJet Ultra Solent Omni Set 120cm but it was not long enough which was switched with 135cm length with successful access. This was followed by repeated attempts of aspirations with zoom 088 and 071 aspiration catheters resulting in near complete recanalization of straight, inferior sagittal sinuses, internal cerebral vein and vein of Galen. Results Two pass Simultaneous Mechanical Y‐Stent Retriever Thrombectomy andContact Aspiration Thrombectomy was performed with minimalrecanalization and reperfusion of straight sinus and inferiorsagittal sinus. This was followed by three pass Contact Aspiration Thrombectomy with large aspiration catheters and AngioJet Sets with near complete recanalization and drainage of straight sinus, inferior sagittal sinus, internal cerebral vein and vein of Galen. After 7 days of close ICU monitoring for malignant intracranial hypertension, patient was ultimately weaned off sedation and bilateral EVDs, extubated and transitioned to oral anticoagulation with significant clinical improvement and minimal residual neurological deficits. Conclusions Limited data is available on mechanical thrombectomies in deep CVST with hemorrhagic transformation. Our study describes a favorable outcome with combined stent retriever and aspiration thrombectomy approach. AngioJet 135cm Aspiration Catheter with Power Pulse lytic are also possible option to treat tough venous intracranial clots. Additional randomized controlled trials are needed to establish superiority between various approaches of mechanical venous thrombectomy in patients who have deep venous sinus thrombosis that fail medical management.

Abstract Number ‐ 228: Two Cases of Vertebrobasilar Dolichoectasia +/‐ Obstructive Hydrocephalus

Introduction Dolichoectasia; “dolichos'' and “ectasia” respectively meaning elongation and distention of blood vessels is a process by which arteries undergo deterioration of the tunica intima or tunica media, resulting in smooth muscle atrophy.1 It can be atherosclerotic, non‐atherosclerotic, and dissection‐related. Prolonged hypertension resulting in breakdown and remodeling of collagen‐elastin meshwork produces the atherosclerotic subtype, though hyperlipidemia also plays a role. The incidence is approximately 3%, higher in males.2 Vessels commonly affected by dolichoectasia are in the vertebrobasilar system but the internal carotid arteries are also at risk. Vertebrobasilar dolichoectasia (VBDE) is radiographically defined by basilar artery diameter &gt; 4.5 mm, though it is sometimes overlooked due to healthy variations in basilar tortuosity and diameter. Smoker’s criteria includes artery diameter, laterality, and bifurcation height.3 Neurovascular compression often occurs, but high‐risk complications of VBDE such as hemorrhagic or ischemic stroke, TIA, brainstem compression, hydrocephalus, or subarachnoid hemorrhage are also possible.4 We present two cases of ventriculomegaly in the setting of VBDE. Methods Case Report Results Case #1: A 40 year‐old man with history of hypertension, gout, anal fissures, and bicuspid aortic valve presented to the hospital for intermittent visual obscuration for 2 weeks. He described it as a “Polaroid picture: starting dark and slowly developing” featuring positional exacerbation with Valsalva, leaning forward, and laying flat. Examination revealed bilateral papilledema, right eye ptosis, and right 6th nerve palsy. CT head showed hydrocephalus. CTA and CTV were negative. MRI brain with contrast showed dilated lateral ventricles (left &gt; right) and anterior third ventricle lacking significant transependymal CSF flow. The distal basilar was tortuous extending towards the mid‐portion of the third ventricle (Figure 1). A precipitating factor was thought to be an epidural for anal fissure surgery 2 months prior. Initially treated with acetazolamide, the patient later underwent endoscopic third ventriculostomy (ETV). One‐year follow‐up showed significant improvement of papilledema with minimal residual visual field deficits. Case #2: A 71 year‐old man with history of atrial fibrillation presented to the Neurology clinic for memory loss. It started with misplacing belongings, complicated by an episode of getting lost while driving to a familiar location. Examination showed 1/5 word recall at 5 minutes and mild impairment of serial sevens and abstract thinking. MRI brain revealed dilatation of the lateral and third ventricles out of proportion to the sulci and fourth ventricle, dolichoectatic basilar artery up to 8 mm with superior displacement of nearby structures and effacement of the anterior third ventricle. Repeat MRI with CSF flow one month later showed unchanged ventricular dilatation favored secondary to volume loss without evidence of an obstructive process. Conclusions These cases characterize the rare phenomenon of VBDE and highlights the importance of acquiring MRI with CSF flow when it presents with hydrocephalus.

Abstract Number ‐ 229: Combined Open and Endovascular Treatment of a Ruptured Aneurysm with Excellent Clinical and Angiographic Outcome

Introduction A 49‐year‐old lady presented to hospital with a WFNS 3 aneurysmal subarachnoid haemorrhage. Her symptomatology included sudden onset headache, vomiting, neck stiffness and mild left‐sided weakness. Her past medical history comprised discoid lupus, scleroderma and hypertension. Plain CT imaging demonstrated a significant blood load distributed primarily around the right Sylvian fissure. CT angiography confirmed two right‐sided middle cerebral artery (MCA) aneurysms. The proximal aneurysm appeared smooth and unruptured. The distal aneurysm appeared irregular and was therefore believed to be the ruptured lesion. The anatomy of this aneurysm precluded endovascular coiling as it was fully incorporated into the inferior MCA M2 branch. Methods Following interdisciplinary discussion, the patient proceeded to open surgical clipping of both aneurysms. A clip was placed across the rupture point of the distal aneurysm but a significant neck was left to permit filling of the distal branches. Post‐operative angiography accordingly showed a small residual component to the aneurysm. On follow‐up angiography one week later, this remnant appeared to have increased in size. The decision was therefore made to endovascularly place a contour device to reduce flow to the persistent portion of the aneurysm. This combined treatment approach resulted in excellent clinical and angiographic outcome. Results The patient was eventually discharged home with a modified Rankin scale score of 1 and had no residual neurological deficit at 1‐year outpatient follow‐up. Similarly, follow‐up catheter angiography at 1‐year demonstrated continued satisfactory appearances with the combination of clip and contour device. Conclusions This case highlights the successful clinical and radiological outcomes of a combined surgical and endovascular approach in aneurysmal subarachnoid haemorrhage ‐ despite an anatomically difficult vascular abnormality ‐ due to good interdisciplinary cooperation and careful patient follow‐up. It furthermore demonstrates the effective use of a relatively novel endovascular device following acute haemorrhage and open surgery which avoided the need for long‐term antiplatelet medication.

Identification of novel compound heterozygous LRBA mutations associated with recurrent hemophagocytic lymphohistiocytosis and CNS manifestations

Background: Lipopolysaccharide-responsive beige-like anchor (LRBA) is an intracellular protein that regulates the recycling of cytotoxic T lymphocyte-associated protein 4 (CTLA4), an immune checkpoint molecule which prevents ongoing activation of T cells. Deficiency of LRBA results in increased trafficking and degradation of CTLA4, and consequently, uncontrolled T cell responses. The phenotypic spectrum of LRBA deficiency arising from biallelic loss-of-function typically includes recurrent infections, autoimmunity, lymphoproliferation, chronic diarrhea, hypogammaglobulinemia, and cytopenia. Aim: To report an atypical presentation of LRBA deficiency arising from a set of compound heterozygous LRBA variants, encompassing recurrent hemophagocytic lymphocytosis (HLH) and neurological manifestations. Methods: Clinical data was gathered through retrospective chart review. Expanded genetic analysis including whole exome sequencing was performed. Results: Our patient initially presented at age 15 months with fever, seizures, and encephalopathy. HLH-work-up showed bicytopenia, elevated ferritin and triglyceride, and low fibrinogen, however, he did not yet meet the diagnostic criteria for HLH. MRI brain and EEG at diagnosis was suggestive of acute necrotizing encephalopathy of childhood. He responded to pulsed IV methylprednisolone treatment with minimal residual neurological deficit on follow-up. At 36 months of age, he had a repeat presentation and rapidly deteriorated. He developed severe encephalopathy with fixed dilated pupils. Whole exome sequencing revealed a set of compound heterozygous missense variants in the LRBA gene, a novel c.2206A&gt;T (p.R736W) and c.5989C&gt;T (p.R1997C) variant. Conclusion: Compound heterozygous mutations in the LRBA gene caused an atypical presentation of recurrent HLH with central nervous system (CNS) manifestations in our patient. Statement of Novelty: We herein report a novel set of compound heterozygous mutations in LRBA with atypical presentation of recurrent HLH with CNS manifestations, thus expanding the known phenotypic spectrum of LRBA deficiency.

Abstract Number ‐ 66: Symptomatic Chronic Internal Carotid Artery Occlusion Managed With Bilateral Common Carotid Angioplasty: A Case Report

Introduction Several guidelines have addressed symptomatic or asymptomatic carotid artery stenosis treatment with intensive medical management and surgical management based on the severity of stenosis [1]. In acute occlusions, endovascular treatment (EVT) and carotid endarterectomy (CEA) with or without prior thrombolytics provide the best recanalization and functional outcomes when compared to intravenous or intra‐arterial thrombolysis alone. There is, however, less robust evidence on management of symptomatic chronic internal carotid artery (ICA) occlusion occurring in tandem with significant contralateral ICA stenosis [2]. In chronic ICA occlusion (ICAO), EVT and carotid endarterectomy (CEA) are technically unfeasible, but indirect procedures have been arising as safe and effective alternatives, notably CEA or stenting of contralateral stenotic ICA [3] and CEA or stenting of ipsilateral external carotid artery (ECA) [4]. We hereby report a case of symptomatic chronic ICAO that was managed with staggered angioplasty and stenting of bilateral common carotid artery (CCA) bifurcations. Methods We hereby present a case report. Results A 62‐year‐old male with atrial fibrillation and hypertension woke up with sudden dysarthria and right upper extremity and facial weakness. NIHSS at presentation was 4. Last seen normal 9 hours prior. Non‐contrast head computerized tomography (CT) did not show acute intracranial abnormality, CT angiogram of head and neck showed severe right ICA stenosis and complete occlusion of the left ICA at cervical, petrous and cavernous segments, with distal reconstitution at the supraclinoid segment with left proximal middle cerebral artery (MCA) thrombus. CT perfusion showed a core infarct volume of 8cc in left MCA territory, mismatch volume of 78cc and ratio of 10.8. Risks of acute neuro‐intervention were deemed to outweigh benefits. Given favorable perfusion imaging, and in concordance with the EXTEND trial [5], tPA was administered. The patient remained stable without hemorrhagic complications with residual deficits of mild right upper extremity weakness and mild expressive aphasia. MRI confirmed left ICA territory ischemic infarcts. Patient underwent stenting of the asymptomatic right ICA at the CCA bifurcation first, followed by left CCA stent after one month with impressive improvement in subsequent perfusion imaging. Conclusions Our case encourages consideration of well‐timed angioplasty and stenting in cases of chronic bilateral carotid artery disease especially when the asymptomatic side is also significantly stenotic

Gonadotropic pituitary adenomas: Two cases report

The pituitary gonadotropic adenoma is an adenoma developed́ in the gonadotropic cells of the anterior pituitary. It can be secreting releasing in excess in blood and urine; the products of its secretion are gonadostimulines (F.S.H. and L.H.) or non-secreting in this case only histo- cytochemical analysis will be able to allow identification. We report two cases of macroadenoma with LH-FSH immunostaining. Pituitary magnetic resonance imaging revealed a macroadenoma. Transphenoidal surgery was incomplete. Immunohistochemical staining showed that the tumor cells were reactive to LH (70%) and FSH (30%). Control pituitary imaging revealed a residual macroadenoma and deficit replacement was started. Hormonal testing for all patients with pituitary adenoma should be performed even in the absence of symptoms of hypersecretion. The treatment of gonadotropic adenomas is surgical. Complementary radiotherapy is usually indicated in case of postoperative tumor remnants with an effect on the prevention of recurrence. Medical treatment (dopaminergic agonists, somatostatin analogues, GnRH agonists and antagonists) is disappointing.

Differential saccade-pursuit coordination under sleep loss and low-dose alcohol.

Ocular tracking of a moving object requires tight coordination between smooth pursuit and saccadic eye movements. Normally, pursuit drives gaze velocity to closely match target velocity, with residual position offsets corrected by catch-up saccades. However, how/if common stressors affect this coordination is largely unknown. This study seeks to elucidate the effects of acute and chronic sleep loss, and low-dose alcohol, on saccade-pursuit coordination, as well as that of caffeine. We used an ocular tracking paradigm to assess three metrics of tracking (pursuit gain, saccade rate, saccade amplitude) and to compute "ground lost" (from reductions in steady-state pursuit gain) and "ground recouped" (from increases in steady-state saccade rate and/or amplitude). We emphasize that these are measures of relative changes in positional offsets, and not absolute offset from the fovea. Under low-dose alcohol and acute sleep loss, ground lost was similarly large. However, under the former, it was nearly completely recouped by saccades, whereas under the latter, compensation was at best partial. Under chronic sleep restriction and acute sleep loss with a caffeine countermeasure, the pursuit deficit was dramatically smaller, yet saccadic behavior remained altered from baseline. In particular, saccadic rate remained significantly elevated, despite the fact that ground lost was minimal. This constellation of findings demonstrates differential impacts on saccade-pursuit coordination with low-dose alcohol impacting only pursuit, likely through extrastriate cortical pathways, while acute sleep loss not only disrupts pursuit but also undermines saccadic compensation, likely through midbrain/brainstem pathways. Furthermore, while chronic sleep loss and caffeine-mitigated acute sleep loss show little residual pursuit deficit, consistent with uncompromised cortical visual processing, they nonetheless show an elevated saccade rate, suggesting residual midbrain and/or brainstem impacts.

Case-matched radiological and clinical outcome evaluation of interlaminar versus microsurgical decompression of lumbar spinal stenosis

PurposeEndoscopic spine surgery is a globally expanding technique advocated as less invasive for spinal stenosis treatment compared to the microsurgical approach. However, evidence on the efficiency of interlaminar full-endoscopic decompression (FED) vs. conventional microsurgical decompression (MSD) in patients with lumbar spinal stenosis is still scarce. We conducted a case-matched comparison for treatment success with consideration of clinical, laboratory, and radiologic predictors.MethodsWe included 88 consecutive patients (FED: 36/88, 40.9%; MSD: 52/88, 59.1%) presenting with lumbar central spinal stenosis. Surgery-related (operation time, complications, length of stay (LOS), American Society of Anesthesiologists physical status (ASA) score, C-reactive protein (CRP), white blood cell count, side of approach (unilateral/bilateral), patient-related outcome measures (PROMs) (Oswestry disability index (ODI), numeric rating scale of pain (NRS; leg-, back pain), EuroQol questionnaire (eQ-5D), core outcome measures index (COMI)), and radiological (dural sack cross-sectional area, Schizas score (SC), left and right lateral recess heights, and facet angles, respectively) parameters were extracted at different time points up to 1-year follow-up. The relationship of PROMs was analyzed using Spearman’s rank correlation. Surgery-related outcome parameters were correlated with patient-centered and radiological outcomes utilizing a regression model to determine predictors for propensity score matching.ResultsComplication (most often residual sensorimotor deficits and restenosis due to hematoma) rates were higher in the FED (33.3%) than MSD (13.5%) group (p < 0.05), while all complications in the FED group were observed within the first 20 FED patients. Operation time was higher in the FED, whereas LOS was higher in the MSD group. Age, SC, CRP revealed significant associations with PROMs. We did not observe significant differences in the endoscopic vs. microsurgical group in PROMs. The correlation between ODI and COMI was significantly high, and both were inversely correlated with eQ-5D, whereas the correlations of these PROMs with NRS findings were less pronounced.ConclusionsEndoscopic treatment of lumbar spinal stenosis was similarly successful as the conventional microsurgical approach. Although FED was associated with higher complication rates in our single-center study experience, the distribution of complications indicated surgical learning curves to be the main factor of these findings. Future long-term prospective studies considering the surgical learning curve are warranted for reliable comparisons of these techniques.

Abstract TP75: Waking Up To A New Wake-Up Stroke Protocol Is Feasible And Safe

Introduction: Up to 25% of strokes are recognized upon awakening. Recent studies have demonstrated that a “tissue clock” rather than a time clock can be used to identify patients who may benefit from intravenous thrombolytics (IVT) beyond 4.5 hours from last known well (LKW). Consistent access to hyperacute MRI limits many centers from treating wake-up stroke patients. We created a formal protocol of clinical and imaging criteria to standardize evaluation and management of wake-up strokes. Methods: This retrospective, observational study reviewed consecutive patients admitted to our Comprehensive Stroke Center who qualified for the wake-up protocol between February 2022 and June 2022. The implemented protocol, based on clinical trials’ inclusion criteria, is comprised of the following: 1) arrival within 12 hours from LKW and within 4.5 hours from symptom discovery; 2) high suspicion for acute ischemic stroke; 3) no contraindication to MRI; 4) NIHSS of at least 4; 5) baseline mRS 0-3; 6) no absolute contraindications to IVT. For patients meeting above inclusion criteria, emergent MRI with perfusion was performed. Diffusion-FLAIR mismatch (signal intensity ratio) and diffusion-perfusion mismatch were reviewed to determine thrombolysis eligibility by a trained neuroradiologist or vascular neurologist. Results: Ten patients qualified for the wake-up protocol in the first five months of protocol implementation. Median NIHSS was 7, median LKW to arrival time was 8 hours, and median door to MRI time was 72.5 minutes. A final diagnosis of ischemic stroke was made in 80% of these cases. Overall, 50% were eligible for IVT based on our criteria, and 30% received thrombolysis. Median door to needle time was 92 minutes (range 75-117). There were no symptomatic intracranial hemorrhages. All patients treated with IVT were discharged home with no to minimal residual deficits with mRS 0-1 and median NIHSS at discharge of 2 (range 0-4). Conclusion: A formal protocol for wake-up stroke management allowed a streamlined approach to expand the number of IVT-eligible cases. Continued efforts are needed to improve door to needle times in such cases and to follow clinical courses of treated patients.

Treatment of advanced trigger finger by ulnar superficialis slip resection: Long-term outcome and predictive factors for poor prognosis

The aim of this study was to evaluate the outcome of ulnar superficialis slip resection and to determine predictive factors for poor prognosis in patients with advanced trigger finger. Over a 5-year-period, 55 patients (58 fingers) were included. After surgery, two groups were identified: group 1, with complete extension or <10° extension deficit in the proximal interphalangeal (PIP) joint (n = 27 fingers/27 patients); and group 2, with ≥10° residual PIP extension deficit (n = 31 fingers/28 patients). Factors associated with PIP extension deficit were assessed on logistic regression. There was a median extension gain of 20° (range, 10−30°) after surgery. The difference between pre- and post-operative extension deficits was significant (p < 0.001). There was no significant inter-group difference in DASH score (p > 0.9). Two predictive factors were found: >12 months’ preoperative symptom duration (OR = 1.02; p = 0.045), and lack of self-rehabilitation (OR = 20; p < 0.001). Ulnar superficialis slip resection was effective in advanced trigger finger. Hand surgeons should operate early on these patients, and encourage self-rehabilitation. Level of evidence4

Joshi's external stabilization system fixator – A mini solution to avert major disabilities in hand injuries

Background: Fractures of hand bones are often considered minor injuries and treatment is either delayed or neglected. These fractures are usually treated conservatively that leaves behind a residual functional deficit. Surgical intervention should be considered for open, unstable, multiple, comminuted, or intra-articular fractures. Standard surgical treatment includes the use of K-wire, plate, or mini-screws which are associated with unsatisfactory results and high complication rates. Joint stiffness is a commonly reported complication with most of the existing devices used for hand bone fractures. There is a deficit of data pertaining to the effectiveness of Joshi's External Stabilization System (JESS) in avoiding joint stiffness. Joshi's external fixator is a reliable treatment of phalangeal and metacarpal fractures of the hand. It is an economical, simple, lightweight, and stable contract. Patients and Methods: We report a prospective cohort study of 30 patients of hand bone fracture, 10–60-year age range, treated by JESS. Functional evaluation was made using the Duncan et al. scoring. Results: The results recorded were excellent in 31.58% of cases, good in 42.11% of cases, fair in 21.05%, and poor in 5.26% of patients. Conclusion: JESS ex-fix for hand is a useful construct that allows early mobilization of nearby joints. It can be considered a suitable choice for the management of phalangeal and metacarpal fractures of hand to deliver good functional outcome.

ГЕМОРРАГИЧЕСКИЕ ИНСУЛЬТЫ У ДЕТЕЙ РАННЕГО ВОЗРАСТА

To date, cerebrovascular diseases of childhood are poorly understood. The need to study hemorrhagic strokes in children is due to the high prevalence in early childhood, the difficulty in identifying the causes and the non-specificity of the first signs of pathology. At different stages of child development, the etiological significance of various pathogenic factors is not the same. The purpose of this study - to analyze the results of diagnosis and treatment of intracranial complications in late hemorrhagic disease of the newborn. Methods. 158 cases of treatment of patients with intracranial hemorrhages against the background of vitamin-K dependent hemorrhagic syndrome were chosen as the objects of the study. Among the sick boys prevailed and amounted to 76 percent. At the age of 40 days ± 2, the disease began in 129 (86.6%) patients. The results of treatment were monitored in 158 patients within the period from one to 3 months. Indicators reflecting the results of treatment were subjected to statistical analysis. Results. According to the type of hematoma, the patients were distributed as follows - 64 (41.1%) intracerebral hematoma, 31 (20.2%) were diagnosed with subdural hemorrhage, intraventricular hemorrhage was detected in 6 (3.8%) cases, mixed subduralintracerebral hemorrhage was detected in 15 (9.5%) patients. 43 (26.6%) patients were not operated on: with subarachnoid hemorrhages - 34 (21.4%) and 9 patients (5.7%) - with small intracerebral and suberal hemorrhages. Lethal outcome occurred in 29 children (18.4%), mortality after surgery in 8 (5.1%) cases. In 43% of cases, a follow-up study did not reveal a neurological deficit. Conclusions. Full-term infants with a combination of the following factors are susceptible to the occurrence of hemorrhagic disease of the newborn: lack of prophylactic administration of vitamin K preparations, breastfeeding, and transient cholestasis. Timely surgical treatment in most patients gives positive results, despite the operation in a very difficult general condition of the patient and unstable hemostasis. Residual neurological deficit was noted during the follow-up study mainly in patients with primary gross damage to the brain parenchyma and with late diagnosis of the disease.