Residual Neurological Deficits Research Articles

A Unique Presentation of Posterior Reversible Encephalopathy Syndrome

Introduction: Posterior reversible encephalopathy syndrome is a neurologic condition which is often though not always is associated with Pregnancy induced Hypertension. A high index of suspicion in a pregnant patient who presents with seizure and altered sensorium, along with characteristic findings in magnetic resonance imaging which are pathognomic for this syndrome can help clinch the diagnosis. An early definitive diagnosis and prompt management is the key to prevent permanent neurological damage in the patient. Case Report: We report a case of delayed unusual presentation (6 days post partum) of Posterior reversible encephalopathy syndrome [PRES] in a 25 year old pregnant patient of Pregnancy Induced Hypertension, wherein the patient presented six days after the delivery of baby in a unconscious state. She was admitted in intensive care unit and was managed with mechanical ventilation along with other neuroprotective measures. MRI brain was done which helped to clinch the diagnosis of PRES. She had complete recovery without any residual neurologic deficits and was discharged. Conclusion: Prompt and early diagnosis and neuroprotective measures are the keys for an ideal management of Posterior Reversible Encephalopathy syndrome. Also MRI brain is essential to clinch the diagnosis. Keywords: PRES, Pregnancy, Preeclampsia, Eclampsia.

Pre and Post-Operative Computer Tomography Findings of a patient with a Type A Aortic Dissection Extending from the Aortic Valve to Iliac Vessels

Aortic dissection is a high morbidity, high mortality, medical catastrophe. It is twice as common as ruptured abdominal aortic aneurysm and the mortality following acute aortic dissection is often quoted in hours. The presentation of Aortic Dissection is variable and can be diagnostically challenging, which can have a direct effect on mortality in often young and relatively healthy patients. We present the case of a young man who presented to the emergency departments with central chest pain and ST depression laterally on his ECG. A computer tomography (CT) scan revealed The CT scan showed a proximal Type A dissection involving the aortic valve and the coronary arteries, extending down to the iliac vessels. The patient was transferred to a cardiothoracic centre to undergo emergency surgery and had repair of the aortic dissection, he made a good post-operative recovery and has no residual neurological deficit. A further computer tomography scan was performed 8 months later which showed no change in the patient vascular anatomy.

Baclofen Induced Encephalopathy in Patients with Chronic Kidney Disease

Hiccups are manifestation of uremic syndrome. Baclofen had been used in uremic hiccups, but its usage has been described in literature with development of neurotoxicity in patients with renal failure. The case series reports three patients of Chronic Kidney Disease (CKD) that were on haemodialysis. All of them had intractable hiccups, for which Baclofen was administered. They developed encephalopathy within 24-48 hours of ingestion of Baclofen. The drug was discontinued and the patients improved within 36-48 hours. They were finally discharged with no residual neurological deficit.

Hyperhomocysteinemia – A treatable cause of cerebral venous thrombosis in young

Mild hyperhomocysteinemia is an established risk factor for deep vein thrombosis. Here, we report a case of a 28-year-old male with complaints of severe headache and vomiting for 7 days, and he also had two episodes of generalised tonic clonic seizures (GTCS) type of convulsions. Magnetic resonance imaging + magnetic resonance venography showed acute infarct with hemorrhagic transformation in the right occipital region and venous thrombosis of the right transverse sinus, right sigmoid sinus, and superior sagittal sinus. All laboratory investigations including protein C, S, and B12levels were found to be normal except for serum homocysteine which was 29.20 μmol/L. After anticoagulation therapy, this young patient completely recovered without any residual neurological deficit. Hence, we suggest that hyperhomocysteinemia should also be a risk factor for cerebral venous thrombosis (CVT). Since this condition can be effectively and safely corrected by drugs, we suggest that homocysteine levels should be routinely determined in patients with idiopathic CVT, and even mildly increased levels corrected pharmacologically, in the hope of reducing the risks associated with this condition.

P835 Mitral valve abscess complicating infective endocarditis

Abstract Funding Acknowledgements n/a Background Health care associated infective endocarditis (HAIE) accounted for u to 30% of infective endocarditis (IE) cases, it tends to affect patients with a poor clinical condition and represents a considerable in-hospital mortality. Case A 75-years old gentleman with end-stage renal failure secondary to polycystic kidney disease had commenced hemodialysis via a tunneled hemodialysis catheter 3 months ago, presented for pre-operative evaluation before vascular surgery for acute left lower limb ischemia, patient gave history of fever for the past month partially responding to antipyretics along with recent ischemic cerebrovascular stroke with no residual neurological deficits. On examination he had a blood pressure of 110/70 mmHg, a heart rate of 100 bpm, a temperature of 38oC, and a harsh pansystolic murmur over the apex. Laboratory results revealed leukocytosis elevated CRP and blood cultures were positive for staphylococcus aureus. Electrocardiography showed sinus tachycardia. Methods and Results 2D-Trans-Thoracic Echocardiography (TTE) revealed the presence of echogenic rounded mobile mass measured 2x2 cm attached to the atrial surface of the posterior mitral valve leaflet. There was a severe mitral valve regurgitation and the regurgitant jet was directed anteriorly swirling around the mass. The left ventricle dimensions and function were normal. 2D-Trans-esophageal Echocardiography(TEE) was done for better visualization of the mass and it"s attachment. The mass was overlying the atrial surface of the posterior leaflet middle P2 scallop with a small echo-lucent cavity (abscess formation) in the leaflet in addition to another smaller mass at the atrial surface of the anterior leaflet. The aortic, tricuspid and pulmonary valves were normal in structure and function Discussion Echocardiography is a crucial imaging modality in a patient with multiple systemic emboli to rule out cardio-embolic source of embolization. TEE is of added value along with TTE in better definition of masses and detection of IE related complication. While the patient was prepared for the vascular surgery to secure the ischemic limb his sensorium was disturbed and became unconscious immediate brain computed tomography showed severe intracranial hemorrhage and the patient died. Conclusions Patient with chronic kidney disease and on hemo-dialysis are highly vulnerable to health care related infective endocarditis and high clinical suspicion should be given in a situation of prolonged fever and embolic events. Mitral valve abscess is a rare complication of infective endocarditis and if occurs it leads to increase mortality. TEE should be an integral part of management of patients with IE to role out serious complications. Abstract P835 Figure. Mitral valve infective endocarditis

Study of Behavioural Activity and Cognitive Impairment in Rats in the Simulation of Pneumococcal Meningitis

Aim. To study neurological disorders in rats when modeling purulent bacterial meningitis (PBM) on the example of pneumococcal meningitis under experimental conditions.Materials and methods. Pneumococcal meningitis was modeled by injecting a suspension containing Streptococcus pneumoniae at a concentration of 5×109 CFU/ml into the subarachnoid space. The degree of neurological disorders was determined by clinical assessment of rat health status, the degree of neurological defi cit, specifi c strength, “Infrared activity monitor”, “Object recognition task” tests.Results. When modeling pneumococcal meningitis in rats, the sum of points of clinical assessment of their health in the 1st day after modeling the pathology is 34.2 % less than the initial, on the 5th — less than 3.4 %, on the 8th day returns to the primary indicator, 5 points. The maximum degree of severity of neurological defi cit was observed in the fi rst four days after meningitis modeling; it was in the 1st day 34 % less than the same indicator in the group of intact animals, on the 2nd day 32.7 % less, on the 3rd day — 30.7 % and on the 4th day — 30.1 %. In the meningitis group on day 10, the distribution of neurological defi cit by severity was as follows: mild — 32 %, medium — 20 %, severe — 16 %, without residual neurological defi cit — 32 %. The specifi c strength of rats in the group of meningitis on the 1st, 5th and 10th day after the development of the pathology was 48.7, 64, and 67.4 % of the baseline specifi c strength. In relation to intact animals, the index of recognition of short-term memory in rats of the meningitis group is 2.3 times greater, and the index of recognition of long-term memory is 1.7 times greater.Conclusion. The dynamics of neurological disorders in rats in the simulation of PBM can be determined using the methods of assessing behavioural and cognitive status. In rats, when modeling pneumococcal meningitis, neurological disorders are maximally expressed on the 1st day of the disease. Then there is a distinct positive dynamic up to 5 days of the disease. From 6 to 10 days positive dynamics is present, but insignifi cant.

Effects of horse-riding therapy and rhythm and music-based therapy on functional mobility in late phase after stroke.

BACKGROUND:Persons with stroke commonly have residual neurological deficits that seriously hamper mobility.OBJECTIVE:To investigate whether horse-riding therapy (H-RT) and rhythm and music-based therapy (R-MT) affect functional mobility in late phase after stroke.METHODS:This study is part of a randomized controlled trial in which H-RT and R-MT was provided twice weekly for 12 weeks. Assessment included the timed 10-meter walk test (10 mWT), the six-minute walk test (6 MWT) and Modified Motor Assessment Scale (M-MAS).RESULTS:123 participants were assigned to H-RT (n = 41), R-MT (n = 41), or control (n = 41). Post-intervention, the H-RT group completed the 10 mWT faster at both self-selected (–2.22 seconds [95% CI, –3.55 to –0.88]; p = 0.001) and fast speed (–1.19 seconds [95% CI, –2.18 to –0.18]; p = 0.003), with fewer steps (–2.17 [95% CI, –3.30 to –1.04]; p = 0.002 and –1.40 [95% CI, –2.36 to –0.44]; p = 0.020, respectively), as compared to controls. The H-RT group also showed improvements in functional task performance as measured by M-MAS UAS (1.13 [95% CI, 0.74 to 1.52]; p = 0.001). The gains were partly maintained at 6 months among H-RT participants. The R-MT did not produce any immediate gains. However, 6 months post-intervention, the R-MT group performed better with respect to time; –0.75 seconds [95% CI, –1.36 to –0.14]; p = 0.035) and number of steps –0.76 [95% CI, –1.46 to –0.05]; p = 0.015) in the 10 mWT at self-selected speed.CONCLUSIONS:The present study supports the efficacy of H-RT in producing immediate gains in gait and functional task performance in the late phase after stroke, whereas the effectiveness of R-MT is less clear.

COT-22 TIMING OF SURGERY AND BEVACIZUMAB THERAPY FOR MALIGNANT GLIOMAS

BACKGROUNDThe drug manufacturer recommends postponing initiation of bevacizumab for malignant gliomas at least 4 weeks later postoperatively. Malignant glioma patients with significant neurological deficits due to postoperative residual tumors are preferably needed earlier bevacizumab therapy that expecting improvement of neurological state and brain edema. There is a literature review indicating that the timing for administration of postoperative bevacizumab was at least 2 weeks. The authors assessed the safety,tolerability,efficacy for bevacizumab therapy less than 4 weeks later postoperatively.METHODSSix patients of malignant gliomas with residual tumors and neurological deficits were treated by bevacizumab (10mg /kg every 2 weeks) therapy 2–3 weeks later postoperatively with chemoradiotherapy. Patients included 31-year-old female with thalamic-midbrain glioblastoma (initial),11-year-old female with anaplastic ependymoma (recurrent),71-year-old female with initial cervical cord anaplastic astrocytoma (initial),88-year-old female bilateral frontal glioblastoma (initial),27-year-old female with thalamic midbrain glioblastoma (initial) and 3-year-old female with brain stem glioblastoma (initial).RESULTSAll the patients did not experienced hemorrhage and impair wound healing. Every patient neurological state and perifocal brain edema following bevacizumab therapy demonstrated early improvement. Earlier bevacizumab therapy did not delay and cease postoperative chemoradiotherapy.CONCLUSIONSInitiation of bevacizumab therapy 2–3 weeks later postoperatively seems to be safe and effective for malignant glioma patients with worse neurological state due to residual tumor and perifocal edema. The optimal interval which balances the risk of complications and the risk of tumor progression should be considered.

Multiple Sclerosis Exacerbation Associated With High-Altitude Climbing Exposure

The spectrum of the neurological effects of high-altitude exposure can range from high-altitude headache and acute mountain sickness, to the more severe end of the spectrum with high-altitude cerebral edema. In general, patients with known unstable preexisting neurological conditions and those patients with residual neurological deficits from a preexisting neurological condition are discouraged from climbing to high altitudes because of the risk of exacerbation or worsening of symptoms. Although multiple sclerosis exacerbations can be triggered by environmental factors, high-altitude exposure has not been reported as a potential trigger. We are reporting the case of a multiple sclerosis exacerbation presenting in an active duty U.S. Air Force serviceman upon ascending and descending Mt. Fuji within the same day.

What can DTI add in acute ischemic stroke patients?

BackgroundCerebrovascular stroke is one of the leading causes of death worldwide. Imaging with conventional MR techniques cannot provide reliable information as regard the integrity of the white matter tracts and therefore limiting its ability to predict the clinical outcome. While prediction of the motor outcome becomes more crucial for determining the specific rehabilitation strategies and final clinical outcomes, the purpose of this study was to assess the value of diffusion tensor MR imaging in patients with acute ischemic stroke as a prognostic imaging modality to predict the clinical outcome.ResultsA significant statistical association was found between the tractography findings and the clinical score at admission (p 0.0005) and the clinical recovery after 3 months (p 0.001). Residual neurological deficits were found in patients with disrupted tracts; on the other hand, near complete clinical recovery was found in patients with non-disrupted tracts. Also, significant statistical association was found between the degree of FA reduction in the affected tracts and the clinical score at admission (p 0.001) and the clinical recovery after 3 months (p 0.01). Correlation between the FA values at the site of infarctions and the corresponding area of the brain on the contralateral side revealed significant statistical difference.ConclusionDTI offers a potential tool for prediction of the clinical outcome of acute stroke patients as it can detect the microstructural changes in the white matter tracts affected by the ischemic lesions which cannot be detected by conventional MRI and therefore can help in determining the rehabilitation strategy

Clinical Profile, Microbiology, Management, and Outcome of Pediatric Brain Abscess at the University of the Philippines- Philippine General Hospital: A 5-Year Retrospective Study (2012-2016)

Objective: To determine the clinical profile, microbiology, management, and outcome of pediatric brain abscess at a tertiary hospital in the Philippines from 2012 to 2016. Methods: A retrospective study and review of medical records of 50 patients aged 18 years old and below diagnosed with brain abscess from 2012 to 2016 was performed. Results: Majority of patients affected were 10 years old and below (74%), with no gender predilection, and mostly underweight/wasted (68%). Coverage for common vaccine-preventable pathogens was low (38% for H. influenzae type b, 2% for S. pneumoniae). Most common signs and symptoms on admission were fever (62%), vomiting (50%), and headache (50%). The top pre-disposing condition was congenital heart disease (46%), mostly Tetralogy of Fallot (33%). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated in 38%) of cases. Sterile cultures comprised 68% of cases. There were two cases of tuberculous abscess. Empiric antibiotics administered for patients seen in 2012 were penicillin G and chloramphenicol, with a shift to a third-generation cephalosporin and metronidazole in the succeeding years. Aspiration with or without drainage was performed in majority of cases (85%). Six underwent complete excision and had a shorter mean length of stay of 57 days, and a lower morbidity rate of 17% with no mortalities. The overall mean length of hospital stay was 65 days. Residual neurologic deficit was observed in 28%, mostly extremity weakness. Mortality rate was 6.8%. No statistical association was found between a predisposing condition and affectation of a particular area of the brain using the Fisher exact test. Conclusion: There should be a high index of suspicion for brain abscess among patients with pre-disposing conditions (i.e. paracranial infection, cyanotic congenital heart disease) presenting with fever, headache, and vomiting. Common etiologic agents in this study were MRSA and Enterococcus. The isolates were sensitive to the antibiotics recommended for empiric therapy, particularly parenteral third generation cephalosporin + metronidazole for 6 to 8 weeks. Patients with sterile cultures were also continued on this regimen. With the high resistance rates to oxacillin, vancomycin should be considered for abscesses arising from paracranial infections and for those with breaks in the skull post-trauma. There was an overall reduction in mortality due to improved imaging studies andidentification of pathogens for definitive treatment, as well as improved surgical techniques over time. A considerable number of affected children however had neurologic deficits upon discharge.

Paraspinal Congenital Infantile Fibrosarcoma: A Case Report

Congenital infantile fibro-sarcomas (CIFS) are rare, locally aggressive mesenchymal tumors that usually develop from soft tissue of distal extremities. CIFS arising from paraspinal region are extremely rare and only few cases have been reported. A left thoracic paraspinal swelling in a female fetus was noted on 20-week antenatal scan of a primigravida. The swelling was monitored with regular antenatal scans. The baby was born at term and was well at birth. Serum AFP and Beta HCG were within normal age limits. MRI scan confirmed an aggressive tumor infiltrating the paraspinal muscles but not the spinal cord. The mass grew very rapidly in size within a few days, and was excised on day 7 of life. Histopathology and Immunohistochemistry diagnosed the mass to be a Fibrosarcoma. No chemotherapy or radiotherapy was given. The baby is well with no recurrence or residual deformity or neurological deficit after 18 months of follow up.Paraspinal CIFS are extremely rare but can be detected antenatally as early as 20 weeks of gestation. Complete surgical excision is the treatment of choice.

Stroke and Myocardial Infarction (MI) in Hereditary Thrombotic Thrombocytopenic Purpura (HTTP): Similarities to Sickle Cell Anemia (SSA)

Two recent large case series of patients with HTTP (UK Registry, Blood 2019; 133:1644; International Registry [IR], Haematologica 2019; in press) have reported that stroke is common (UK 25%, IR 31%) and MI is uncommon (IR 4%, UK not reported). The UK case series reported that 5 (7%) patients died; deaths were not reported in the IR case series. No data were reported on the ages when stroke, MI or death occurred (Table 1). To learn individual patient data, we searched MEDLINE and PubMed and identified 76 case reports/series describing 159 patients. Articles were filtered by publication date from 2001, when HTTP was first defined, through April 2019, and needed to report individual patient data to be included. 5 additional articles that focused on occurrence of stroke were excluded; none focused on MI. HTTP was documented by ADAMTS13 activity <10% and biallelic ADAMTS13 mutations in 152 patients; 7 siblings who had characteristic clinical features of TTP but who had died before the diagnosis of HTTP was documented were also included. Approximately 68 of the 159 patients were included in the IR report; none were included in the UK report. 111 (70%) of the 159 patients were reported because they had novel ADAMTS13 mutations; the 48 other patients were reported for clinical issues (e.g., pregnancy, delayed diagnosis, development of ADAMTS13 inhibitor). Because the objective of these reports was not to describe stroke or MI, we believe that they provide objective evidence for the occurrence and characteristics of stroke and MI. Table 1 describes our 159 patients and compares them to the UK and IR data. 43 (27%) of our 159 patients had a symptomatic stroke, occurring at ages 1 day-79 years (median age, 19 years); two were diagnosed on autopsy. Clinically silent strokes were not reported. 11 of these 43 patients were included in the IR report. 4 of the 43 patients had hemorrhagic strokes; the others were assumed to be ischemic. 4 patients had been receiving regular plasma prophylaxis. 35 (81%) strokes occurred before HTTP was diagnosed. In 2 patients, stroke occurred with neither thrombocytopenia nor anemia. Of the 43 patients with stroke, 13 had recurrent strokes. 9 patients with reported stroke had died at the time of the case report. Of the 34 surviving patients, 9 had residual neurological deficits. 5 (3%) patients had an MI, occurring at ages 2-50 years (median age, 20 years); none were included in the IR report. In 3 patients, MI was diagnosed on autopsy; 4 patients had a prior or concurrent stroke. 17 (11%) patients died at ages 2-79 years (median age, 22 years). The median age of the last follow-up evaluation was 24 years. Among the case reports, not all clinical data described in Table 1 were reported for each patient. The actual frequency of stroke, MI, and death may be greater because we assumed that if these events were not reported, they did not occur. The frequencies of stroke and MI in our case report data are similar to the frequencies reported by the UK and International Registries, supporting the validity of our data. Our data emphasize the risk for stroke and death at a young age, although follow-up to older ages was limited. Our data also confirm the observation of the IR report that MI is uncommon. The duration of survival of patients with HTTP remains unknown because of the limited duration of follow-up. Our data for stroke in HTTP patients are strikingly similar to data for stroke in patients with SSA. In both disorders stroke is common and occurs at a young age (Figure 1, SSA data are from Powars, Medicine 2005; 84:363). Among all 1056 SSA patients, 116 (11%) had an overt stroke (median age, 20 years); clinically silent strokes were not reported. Most patients with HTTP (77%) and SSA (75%) had their first stroke before age 30. In the 1056 SSA patients, MI was not reported. The pathogenesis of stroke in patients with HTTP and SSA may be similar: embolic (platelet-von Willebrand factor complexes in HTTP, sickle cell complexes in SSA) rather than atherosclerosis. In both disorders the efficacy of anti-platelet or anticoagulant agents to prevent recurrent stroke is uncertain. The lower frequency of MI in patients with HTTP and SSA suggests that the brain is more vulnerable to the infarction caused by these disorders. Our data from a collection of case reports must be confirmed by long-term follow-up of individual patients. Disclosures No relevant conflicts of interest to declare.

Bilateral refractory subdural hygromas following intrathecal methotrexate injections for B-Cell Acute Lymphocytic Leukemia

BackgroundSubdural hygroma (SDG) is an important complication after intrathecal injections of medications. SDG develops because of a cerebrospinal fluid leak into subdural space. Case descriptionWe report a case of 69 years old male who presented to the hospital with changes in mental status and hemodynamic instability. The patient was a known case of B-Cell Acute Lymphoblastic Leukemia (B-ALL) and was undergoing intrathecal injections of methotrexate (MTX) and intensive chemotherapy. Patient focal neurological deficits were correlated with the neuroimaging findings which showed bilateral subdural hygromas. He has received intrathecal injections of MTX almost 6 weeks ago. Surgical drainage of subdural hygroma was done but the refractory nature of hygroma left the patient with residual mass effects and neurological deficits. ConclusionAs physicians, we should be aware of a fatal but rare complication of intrathecal injections and one of them this patient developed as SDG.

Evaluating pediatric spinal low-grade gliomas: a 30-year retrospective analysis.

Most pediatric spinal tumors are low-grade gliomas (LGGs). Characterization of these tumors has been difficult given their heterogeneity and rare incidence. The objective was to characterize such tumors diagnosed at our institution. Spinal tumors diagnosed in our pediatric patients between 1984 and 2014 were reviewed retrospectively. Demographics, presentation, pathology, imaging, management, and sequelae were examined. Forty patients had spinal LGG tumors, 24 (62%) of which were pilocytic astrocytomas. The most common initial presentations were pain (n = 15), partial extremity paralysis (n = 13), and ataxia (n = 11), with the diagnosis frequently delayed by months (median = 5.9 months, range 4 days-6.2 years). Twenty-nine patients had some tumor resection, and 8 required adjuvant therapy with chemotherapy (n = 4) or radiation (n = 4) post-resection. Ten other patients received only biopsy for histologic diagnosis, who were treated with chemotherapy (n = 4) or radiation (n = 5) post biopsy. Tumor progression was noted in 16 patients (2 after gross-total resection; 10, partial resection; and 4, biopsy). During the evaluation period, 3 patients died secondary to tumor progression. BRAF status could have shortened progression-free survival: patients with BRAFV600E mutations (n = 3) all experienced progression within 10 months. Long-term sequelae of the disease/treatment were mostly residual neurologic deficits (paresthesia, paralysis), chemotherapy-induced hearing loss, and scoliosis. Spinal LGG is a rare entity with significant long-term effects. Although surgery is the most common initial treatment option, more in-depth analysis of molecular biomarkers may improve stratification and prognostication.

SUCCESSFUL EXTRACORPOREAL CPR OF A PATIENT WITH A BULKY MEDIASTINAL MASS AND ACUTE AIRWAY COMPROMISE

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: The applications of extracorporeal membrane oxygenation (ECMO) continue to evolve. Its role in cases of critical airway compression and acute airway emergencies deserve better recognition. CASE PRESENTATION: An 18-year-old male presented with cough and orthopnea. Chest imaging revealed a massive anterior mediastinal mass with significant compression of the distal trachea and mainstem bronchi causing central airway compromise. An endobronchial ultrasound-guided transbronchial biopsy diagnosed a primary mediastinal B-cell lymphoma (PMBCL). A covered metal stent was deployed in the distal trachea and left main stem to negotiate the obstruction and decrease airway resistance and inflation pressures on the ventilator. On day 9 of hospital admission, a rigid bronchoscopy was performed revealing coarse granulation tissue emeshed within the stent, the manipulation of which resulted in uncontrolled airway bleeding and severe respiratory failure refractory to conventional mechanical ventilation requiring emergent initiation of venovenous (VV) ECMO. Midway during the procedure the patient suffered a respiratory arrest requiring cardiopulmonary resuscitation. A hybrid configuration (veno-arterio-venous or VAV) ECMO was deployed to support the embarrassed cardio-pulmonary apparatus. The cardiac function recovered promptly without residual neurological deficit and arterial limb decannulation was performed the following day. VV-ECMO support was continued with concomitant radio- and chemotherapy until day 49. On day 89, bronchoscopy was performed showing significant improvement in airway patency. DISCUSSION: ECMO has traditionally been utilized as a bridge to definitive therapy. As such, it has rarely been used in patients with central airway obstruction or acute airway emergencies [1,2]. In the few case reports of ECMO deployment for central airway obstruction, the definitive therapy was airway stenting or tumor debulking. PMBCL is chemosensitive and we show that ECMO can allow time for chemotherapy to reduce the tumor burden and relieve airway compression. Finally, we show that VV-ECMO can be used as a rescue modality in acute airway emergencies when traditional approaches to airway management have failed. CONCLUSIONS: ECMO can be used as bridge to chemotherapy in PMBCL causing airway compression and as a rescue modality in acute airway emergencies. Reference #1: Hong Y, Jo KW, Lyu J et al. Use of venovenous extracorporeal membrane oxygenation in central airway obstruction to facilitate interventions leading to definitive airway security. J Crit Care. 2013 Oct;28(5):669-74. Reference #2: Willms DC, Mendez R, Norman V et al. Emergency bedside extracorporeal membrane oxygenation for rescue of acute tracheal obstruction. Respir Care. 2012 Apr;57(4):646-9. DISCLOSURES: No relevant relationships by Francisco Almeida, source=Web Response No relevant relationships by Balaram Anandamurthy, source=Web Response No relevant relationships by Shailesh Balasubramanian, source=Web Response No relevant relationships by Alejandro Bribriesco, source=Web Response No relevant relationships by Abhijit Duggal, source=Web Response No relevant relationships by Sudhir Krishnan, source=Web Response No relevant relationships by Mani Latifi, source=Web Response No relevant relationships by Eduardo Mireles-Cabodevila, source=Web Response No relevant relationships by Guramrinder Thind, source=Web Response No relevant relationships by Leslie Tolle, source=Web Response No relevant relationships by James Yun, source=Web Response

Characteristics and Outcomes of Patients with Cerebral Venous Sinus Thrombosis.

ObjectivesCerebral venous sinus thrombosis (CVST) is a disease with potentially serious consequences. The clinical presentation and outcomes of these patients have not been described in Oman. We sought to describe the clinical characteristics and outcomes of patients with CVST.MethodsWe conducted a retrospective study in two tertiary care centers in Oman, which included all Omani adults with radiologically confirmed CVST. We recorded and analyzed patients’ demographic, clinical, and outcome data.ResultsFifty-four patients had radiologically confirmed CVST. The commonest presenting feature was headache (85.0%), followed by focal motor deficits (48.0%) and seizures (27.0%). In this cohort, 24.0% were pregnant or postpartum, 11.0% had an inherited thrombophilia, 11.0% were on hormonal therapy, and 11.0% had systemic lupus erythematous; 38.9% of patients had multiple sinus thrombosis while 35.2% had sigmoid and transverse sinus thrombosis. Antiphospholipid antibody syndrome and infection accounted for 7.0% and 13.0% of causes, respectively, while cancer accounted for 2.0%. No cause was identified in 33.0% of cases. Only 1.9% of patients died, while 29.6% had a residual neurological deficit at hospital discharge. Age was a predictor for residual neurological deficit (p = 0.003).ConclusionsPregnancy and postpartum were the most common predisposing factors for CVST in our cohort. Although the mortality rate is low, the risk of residual neurological deficit remains high. We recommend a prospective study for better characterization and outcome assessment.

Clinical factors, diagnostic delay, and residual deficits in chronic inflammatory demyelinating polyradiculoneuropathy

Management of patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is complicated by the challenging diagnosis, monitoring of disease activity, and treatment response. Real world data about the current practice of care in CIDP are rare, but important to improve clinical guidelines. In this study, we determined the current practice of diagnosis and treatment in relation to the clinical outcome of patients with CIDP in a cross-sectional study in The Netherlands. All patients registered at the Dutch neuromuscular patient organization and patients at the Erasmus Medical Center were approached. CIDP diagnosis was confirmed by using patient files and expert consensus. The response rate was 137/197 (70%) and the diagnosis CIDP was confirmed in 112 patients. The time from onset of symptoms until CIDP diagnosis was median 5 months and > 12 months in 26% of the patients. Patients with a late diagnosis (>5 months) compared to patients with an early diagnosis (≤5 months) more frequently had another initial diagnosis (P < .001), multifocal abnormalities (P = .011), final diagnosis made in university hospitals (P = .001), and more (residual) complaints, also illustrated via two patient reported, validated clinical outcome measures. Although 97% of patients received treatment, 88% reported (residual) neurological symptoms and deficits. CIDP diagnosis is often delayed, especially in patients with atypical CIDP variants. Diagnostic delay may result in delayed initiation of treatment. A more rapid and accurate diagnosis of CIDP may prevent or at least reduce residual neurological deficits and accompanying disability in CIDP.

Carotid Artery Injury during Transsphenoidal Pituitary Surgery: Lessons from a 15-Year Modern Microsurgery Cohort.

Background Internal carotid artery (ICA) injury is a rare but potentially catastrophic complication of transsphenoidal resection (TSR) of pituitary tumors, potentially resulting in a host of deficits due to the risk of hemorrhage, ischemia, or even death. The endoscopic endonasal approach (EEA) has gained considerable popularity in the modern era, with few busy neurosurgeons remaining committed to practicing transnasal pituitary microsurgery. Our objective was therefore to characterize the overall incidence of ICA injury in a large, longitudinal, single-surgeon microscopic TSR series conducted during the modern EEA era. Methods Retrospective case series. Results Overall TSR volume by the senior author (F.B.M.) was 817 pituitary tumors during the study period, 2002 to 2017. Within that cohort, two instances of ICA injury were identified (0.2%), including one each with Cushing's disease and acromegaly, both of whom ultimately recovered without residual neurologic deficit. No pediatric injuries were identified. Conclusion Vascular injury is an exceedingly rare complication of transsphenoidal pituitary surgery. Adjuncts to prevent this complication include careful review of the coronal magnetic resonance imaging, identification of the midline, as needed use of the Doppler, and initial caudal opening of the sellar dura. Although potentially disastrous, good neurologic outcomes may be obtained, with immediate judicious packing followed by immediate digital subtraction angiography to assess vessel patency and secondary complications such as pseudoaneurysm.

Immediate Treatment Outcome of Convulsive Status Epilepticus Following a Specific Management Protocol

Background: Status epilepticus (SE) is a medical and neurologic emergency. Rapid and aggressive treatmentis required to prevent neuronal damage, systemic complications and death. Standardized treatment guidelines may improve the quality of emergency managementof SE.&#x0D; Objectives: The objective of the present study was to assess under lying causes of seizure and the immediate outcome of treatment following the specific proposed management protocol care.&#x0D; Methodology: This cross-sectional study was undertaken on 94 consecutive cases admitted inPediatrics department of Dhaka Medical College Hospital, Dhaka diagnosed as convulsive status epilepticus, age&lt;15 years from September, 2012 – February, 2013. Cases were treated with specific institutional protocol. Under lying causes, outcome of the treatment and side effects of the drugs used were analyzed.&#x0D; Results: Among 94 cases, most of the patients belonged to 6 months - 5 years (73.34%), M: F was1.17:1. The leading presenting features were fever (75.53%), headache (36.17%), meningeal irritation (22.34%).Major causes of convulsive status epilepticus were febrile convulsion (42.6%), meningitis (22.3%), and epilepsy (21.3%), more than two-third (71%) had GTCS, 29% had focal seizure. Most of them presented within 6 hours of convulsion and nearly half of the patient responded to per-rectal diazepam with complete recovery and without any residual problems. A very few cases developed immediate or late behavioral problems or residual neurological deficit like hemiplegiaand epilepsy.&#x0D; Conclusion: Establishing causative factors and early intervention with specific treatment protocol can make rapid seizure control with better outcome.&#x0D; Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 33-37