Residual Paresis Research Articles

Primary Total Knee Replacement using Rotating Hinge Implants in Poliomyelitis: A Case Series and Review of the Literature.

The results of primary total knee replacement (TKR) using hinge implants performed in the Indian population with post-polio residual paresis (PPRP) are unknown. The purpose of this study was to report the outcome of primary rotating hinge TKR in Indian patients with PPRP at a minimum follow-up of 12 months. We retrospectively reviewed the clinical and radiological records of six patients treated with primary rotating hinge TKR. Pre-and post-operative (at final follow-up) knee range of motion (ROM), knee sagittal deformity, knee society score (KSS), and Oxford knee score (OKS) were compared to determine improvement in function. Six rotating hinge TKRs (five female and one male patient) were analyzed for this study. At a mean follow-up of 27 ± 22 months (range, 12-71 months), the mean pre-operative KSS of 50.6 ± 2.5 significantly improved (P < 0.0001) to 72.5 ± 1.6, and the mean pre-operative OKS of 23.6 ± 1.6 significantly improved (P < 0.0001) to 35.3 ± 1.7. The mean pre-operative knee ROM of 94° ± 10° changed to 92° ± 4° (P = 0.64) and the mean pre-operative sagittal deformity of 7° ± 23.5° changed to -3° ± 2.5° (P = 0.32) at final follow-up. None of the knees had any intra- or post-operative complications or showed radiologic evidence of post-operative loosening, subsidence, or periprosthetic radiolucent lines at the final follow-up. Rotating hinge TKR gave excellent clinical and radiological results at a mean follow-up of 27 months in the present study. Despite TKR being a technically challenging procedure in patients with poliomyelitis-affected limbs, a rotating hinge design, along with meticulous surgical technique, can significantly improve function in such patients.

Patient-tailored transcranial direct current stimulation to improve stroke rehabilitation: study protocol of a randomized sham-controlled trial

BackgroundMany patients do not fully regain motor function after ischemic stroke. Transcranial direct current stimulation (TDCS) targeting the motor cortex may improve motor outcome as an add-on intervention to physical rehabilitation. However, beneficial effects on motor function vary largely among patients within and across TDCS trials. In addition to a large heterogeneity of study designs, this variability may be caused by the fact that TDCS was given as a one-size-fits-all protocol without accounting for anatomical differences between subjects. The efficacy and consistency of TDCS might be improved by a patient-tailored design that ensures precise targeting of a physiologically relevant area with an appropriate current strength.MethodsIn a randomized, double-blinded, sham-controlled trial, patients with subacute ischemic stroke and residual upper-extremity paresis will receive two times 20 min of focal TDCS of ipsilesional primary motor hand area (M1-HAND) during supervised rehabilitation training three times weekly for 4 weeks. Anticipated 60 patients will be randomly assigned to active or sham TDCS of ipsilesional M1-HAND, using a central anode and four equidistant cathodes. The placement of the electrode grid on the scalp and current strength at each cathode will be personalized based on individual electrical field models to induce an electrical current of 0.2 V/m in the cortical target region resulting in current strengths between 1 and 4 mA. Primary endpoint will be the difference in change of Fugl-Meyer Assessment of Upper Extremity (FMA-UE) score between active TDCS and sham at the end of the intervention. Exploratory endpoints will include UE-FMA at 12 weeks. Effects of TDCS on motor network connectivity and interhemispheric inhibition will be assessed with functional MRI and transcranial magnetic stimulation.DiscussionThe study will show the feasibility and test the efficacy of personalized, multi-electrode anodal TDCS of M1-HAND in patients with subacute stroke patients with upper-extremity paresis. Concurrent multimodal brain mapping will shed light into the mechanisms of action of therapeutic personalized TDCS of M1-HAND. Together, the results from this trial may inform future personalized TDCS studies in patients with focal neurological deficits after stroke.

Use of Botulinum Toxin for Limb Immobilization for Rehabilitation in Rats with Experimental Stroke.

Motor rehabilitation strategies after unilateral stroke suggest that the immobilization of the healthy, unimpaired limb can promote the functional recovery of a paretic limb. In rodents, this has been modeled using casts, harnesses, and other means of restricting the use of the non-paretic forelimb in models of experimental stroke. Here, we evaluated an alternative approach, using botulinum toxin injections to limit the function of the non-paretic forelimb. Adult male rats were subjected to permanent ligation of the left distal middle cerebral artery, resulting in right forelimb paresis. The rats were then subjected to: (1) no treatment; (2) botulinum toxin injections 1 day post stroke; or (3) cast placement 5 days post stroke. Casts were removed after 5 weeks, while the botulinum toxin injection effectively immobilized subjects for approximately the same duration. Rats with bilateral forelimb impairment due to the stroke plus casting or botulinum injections were still able to feed and groom normally. Both immobilization groups showed modest recovery following the stroke compared to those that did not receive immobilization, but the casting approach led to unacceptable levels of animal stress. The botulinum toxin approach to limb immobilization had both advantages and disadvantages over traditional physical limb immobilization. The major advantage was that it was far less stress-inducing to the subject animals and appeared to be well tolerated. A disadvantage was that the paresis took roughly 10 weeks to fully resolve, and any degree of residual paresis could confound the interpretation of the behavioral assessments.

Clinical Presentation, MRI Characteristics, and Outcome of Conservative or Surgical Management of Spinal Epidural Empyema in 30 Dogs.

Spinal epidural empyema (SEE) represents a neurological emergency in veterinary medicine, but information on this condition is limited to date. This retrospective case series study describes the clinical and magnetic resonance imaging (MRI) features, and the outcome of conservative or surgical management of SEE in 30 dogs diagnosed with SEE from September 2015 to March 2020 at one referral neurology centre. The most frequent clinical sign was pain 28/30 (93%), and 22/30 (73%) showed neurological signs with ambulatory paraparesis/tetraparesis 15/30 (50%), monoparesis 1/30 (3.3%), non-ambulatory paraparesis 3/30 (10%), or paraplegia 3/30 (10%). MRI was valuable for the diagnosis and in the follow-up. In this group of dogs, 24/30 (80%) were conservatively treated and 6/30 (20%) were surgically treated. The outcome was considered favourable in all dogs: 20/30 (66.6%) achieved full recovery (3 surgically treated and 17 medically treated) and 10/30 (33.3%) dogs had an improvement in the neurological signs with residual ambulatory paresis (3 surgically treated and 7 medically treated). Surgical treatment showed better short-term (7 days) outcomes than medical treatment in non-ambulatory paraparetic or paraplegic dogs (33%). Nevertheless, this study suggests that a good recovery may be achieved with conservative treatment even for non-ambulatory or paraplegic dogs. Further prospective studies, with a standardised protocol of diagnostic tests and a homogeneous distribution of conservatively and surgically treated dogs, are needed to establish treatment guidelines.

Bell's Palsy: A Review

Bell's palsy, also known as"acute facial palsy of unknown cause", is a common cranial neuropathy leading to facial muscle paresis or complete paralysis characteristically on one side, occurring suddenly and may progress over 48 hours. It results from facial nerve dysfunction due to trauma or inflammation of the 7th cranial nerve or facial nerve or its branches along its course, primarily in the bony canal. Both sexes are equally affected, and though no age is immune, its incidence rises with increasing age. The risk is high in diabetics, hypertensives, women who are pregnant, obese, and people with upper respiratory tract infections. It is considered chiefly idiopathic and is diagnosed by the exclusion of other causes. Bell's palsy can cause physical and psychological complications and negatively impact patients and their relatives. Thus, early diagnosis and quick cause determination are prime roles in proper treatment. However, the exact etiology of Bell's palsy is unknown, affecting its treatment. Still, determining probable causative and risk factors is critical for employing a targeted treatment approach and requires a comprehensive examination and a complete history. Although the majority of patients recover spontaneously in less than three weeks even if they are not treated. But there is always a risk of residual paresis after treatment or recovery, which may require medical help. This review aims to furnish the most thorough understanding of Bell's palsy, focusing on anatomy, etiology, clinical features, diagnosis, clinical consequences,and preferred therapy approaches.

P18.03.B Long term effects of therapeutic embolization of radiographically suspected meningiomas regarding tumour- and necrosis volume as well as patients' symptoms

Abstract Background Preoperative embolization of radiographically suspected intracranial meningiomas is performed to reduce intraoperative blood loss and to facilitate resection. However, there is paucity of evidence examining the effect of embolization as a sole intervention on the tumor volume and the patient's neurocognitive symptoms. The objective of this study was to investigates the influence of therapeutic embolization on tumor- and necrosis volume and neurocognitive symptoms in absence of surgical intervention. Material and Methods Between January 2019 and June 2021, 4 patients (median age 82, 1 female) with 5 radiographically suspected intracranial meningiomas, underwent endovascular embolization with liquid embolizate and coils, without subsequent surgery. Indication for embolization was history of previous multiple surgery contraindicating further surgical intervention or patients will. Neurological status (on admission, discharge from hospital and 5 months after embolization), medical history, medication, MRI (location, tumor- and necrosis volume, development of edema, complications), DSA (extent of embolization, arterial supply) and procedural complications were recorded. In 3 patients with 4 tumors, an MRI scan was performed. The calculation of tumor- and necrosis volume was done manually with a semiautomatic segmentation tool. One patient with one tumor received CT scans due to a cardiac pacemaker and was therefore excluded from volumetric analysis. Results The average tumor volume was 44,83 ± 13,82 cm3 on admission, 45,33 ± 16,3 cm3 5 days after embolization (+1%) and 39,93 ± 29,39 cm3 (-11%) after 5 months. The average necrosis diameter was 41,76 ± 9,33 mm after 5 days and 6,05 ± 6,43 mm after 5 months. The perifocal oedema decreased in 2/3 Patients. Tumor blood supply was via 2,4 ± 1,34 vessels, 1,2 ± 0,45 vessels were embolised. On admission, 3 patients showed neurocognitive symptoms. At discharge and in the follow-up, in 2 patients the symptoms had improved, one patient experienced a complete symptom regression. In one patient the embolization was complicated by dissection of the middle meningeal artery. The same patients perifocal oedema increased in the further clinical course with accompanying deterioration of the pre-existing hemiparesis from moderate to severe. Supported with dexamethasone medication, the oedema and symptoms declined to a mild residual paresis. None of the patients developed a long-term neurocognitive deficit related to embolization. Conclusion Therapeutic endovascular embolization of radiographically suspected intracranial meningiomas reduced the tumor volume and led to long-term improvement of pre-existing neurocognitive symptoms. In the future, these effects should be verified in larger studies.

Pfizer Vaccine-Associated Parsonage-Turner Syndrome

Parsonage-Turner syndrome, a rare condition with a reported overall incidence of 1.64 cases per 100,000 people. PTS is also characterized by associated delayed upper extremity weakness, muscle atrophy, and painless paresthesias, which tend to diminish slowly and resolve gradually; Although most patients report 80% to 90% muscle strength recovery within 2-3 years, more than 70% of patients experience residual paresis and exercise intolerance. As described in the existing bibliography, the patients reported initial pain in the shoulder and weakness after vaccination that, as it worsened, led them to visit the emergency department. Vaccination is a known cause of this syndrome although there is difficulty in early identification, it is often overlooked or misdiagnosed, Possible immune-mediated mechanisms include molecular simulation and bystander activation, which can occur after any infection or vaccination.

ACUTE FLACCID PARALYSIS REGISTERED FOR THE PERIOD 2012-2020, IN STARA ZAGORA REGION

Acute Flaccid Paralysis (AFP) is a clinical syndrome. There are many infectious and non-infectious causes of AFP. Poliomyelitis caused by the wild polio virus (the natural circulating strain of polio) is one of the causes of AFP. As a part of the worldwide campaign to eradicate polio, all countries do surveillance for polio by looking for clinical cases of AFP. The purpose of the study is to describe the cases of Acute Flaccid Paralysis, without Paresis Nervi facialis, in the Stara Zagora region for the period 2012-2020. Methods: A retrospective, descriptive analysis was performed on the parameters: diagnosis, seasonality, sex, residence, age, clinical data, and comorbidities, results of follow-up examinations, polio vaccine administration, and timeliness of studies. Results: There were 9 cases of AFP, without Paresis nervi facialis, registered and reported for the Stara Zagora region, for the period 2012 – 2020. The children in 3 years old were more affected- 4 patients. About the coverage with polio vaccine: 7 of the patients had 4 doses, 1- had 6 doses, 1 child had 5 doses, and + 1 zero dose. 100% of children are covered, according to their age, with IPV. Follow-up in 6 of the patients is without residual paresis and complications. Residual paresis was found in 1 of the cases. In 2 patients no control examination was performed due to migration. Conclusion: The correct epidemiological diagnosis is the way to timely and corrects clinical diagnosis. AFP Surveillance is of particular importance as well as fecal sampling up to 48 hours, from the onset of paralysis, and follow-up after the 60th day in children &lt;15 years.

Ring-Stripping Retrograde Endarterectomy for Treatment of Common Carotid Artery Occlusion: A Minimally Invasive, Effective Procedure

To evaluate the efficacy and safety of in situ ring-stripping retrograde carotid endarterectomy (IS-RRCEA) in long-segment, symptomatic, chronic common carotid artery occlusion (CCAO). Thirty-nine patients (24 men; 15 women) with symptomatic chronic CCAO who underwent IS-RRCEA in our center were included retrospectively. The mean age of the men was significantly less than that of the women (59.6±5.8 vs. 67.8±6.3years; P<0.001). Risk factors, clinical characteristics, and CCAO classification of patients and effectiveness and safety of IS-RRCEA were analyzed. Patients presented with the following symptoms: dizziness (6; 15.4%), transient ischemic attack (TIA; 33; 84.6%), and decreased vision (15; 38.5%). IS-RRCEA was performed on the left side in 25 (64.1%) cases and on the right side in 14 (35.9%) cases. The technical success rate of the procedure was 100%. Cerebral perfusion on the ipsilateral site improved in all patients. In the postoperative period, stroke and myocardial infarction occurred in one patient, and recurrent laryngeal nerve damage occurred in another; these patients' symptoms mostly resolved except for residual paresis in the stroke patient. Thirty-eight patients (97.4%) were followed for a mean of 29±13.3months after the IS-RRCEA; in 1-year follow-up, 31 patients (31/33; 93.9%) with preoperative TIA have had no TIAs; 2 patients (2/33; 6.1%) have fewer TIAs. Two patients (2/6; 33.3%) with preoperative dizziness have had no dizziness, and 4 (4/6; 66.7%) have had fewer episode of dizziness, no recurrent stenosis (>50%), or recognized occlusion. Our single-center experience indicates that IS-RRCEA is an effective treatment for selected types of CCAO. Studies of the operation in larger populations with longer term follow-up should be conducted.

Optimal Timing of Surgery for Intramedullary Cavernous Hemangioma of the Spinal Cord in Relation to Preoperative Motor Paresis, Disease Duration, and Tumor Volume and Location.

Study Design:Prospective study.Objective:Investigate factors associated with preoperative motor paresis, recovery, ambulatory status, and intraoperative neurophysiological monitoring (IONM) among patients with no preoperative paresis (N group), complete preoperative motor recovery (CR group), and no complete recovery (NCR group) in patients with intramedullary spinal cavernous hemangioma to determine the optimal timing of surgery.Methods:The study evaluated 41 surgical cases in our institute. Disease duration, tumor lesion, manual muscle testing (MMT), and gait at onset, just before surgery, and final follow-up (FU), tumor and lesion volume, IONM, extent of tumor resection, and tumor recurrence were evaluated among N, CR, and NCR groups.Results:Motor paresis at onset was found in 26 patients (63%), with 42% of those in CR group. Disease duration from onset negatively affected stable gait just before surgery and FU as well as lower preoperative MMT (P < .05). Thoracic tumors were associated with patients with unstable gait before surgery (P < .05). Tumor volume was larger in NCR group (P < .05). IONM significantly decreased in NCR and CR groups than in N group (P < .05). The NCR group had residual mild motor paresis at FU (P < .05). Stable gait at FU was similar in N group and CR group, though lower in NCR group (P < .05).Conclusions:Early surgery is generally recommended for thoracic tumors and large tumors during stable gait without motor paresis before long disease duration. Surgery may be postponed until patients recover from preoperative motor paresis to allow optimal surgical outcome. IONM should be carefully monitored in patients with a history of preoperative paresis even with preoperative complete motor recovery.

An Unusual Combination of Posttraumatic Ipsilateral Basal Ganglia Infarction with Contralateral Hemorrhage: A Rare Case Report and Review of Literature

Posttraumatic ipsilateral basal ganglia infarction with contralateral hemorrhage (IBGICH) is an extremely rare neuropathologic entity. Hematomas or infarction of the basal ganglia in head injury have long been recognized but their mechanism has not been revealed clearly. It is presumed to be secondary to rupture and/or vasospasm, followed by thrombosis of the lenticulostriate and/or anterior choroidal artery. This happens by shearing stress as a result of acceleration or deceleration torques. Outcome of traumatic basal ganglia hemorrhage (TBGH) appears favorable unless it is large, associated with coagulation disorders or other intracranial injuries such as diffuse axonal injury, cerebral contusion etc. We present a rare case of a 32-year-old man with traumatic IBGICH (mirror-image). Patient was managed conservatively and discharged with residual paresis and aphasia. Mechanism of trauma, clinical features, management, and most importantly the medicolegal aspect of the TBGH is discussed.

An exploratory intervention study suggests clinical benefits of training in chronic stroke to be paralleled by changes in brain activity using repeated fMRI.

PurposePrevious studies demonstrated changes in sensorimotor network activation over time after stroke that have been interpreted as partly compensatory. Locomotor and balance trainings may improve both mobility and cognition even in chronic stroke and thereby impact on cerebral activation patterns. We here aimed at testing these assumptions in an exploratory study to inform subsequent larger intervention studies.Patients and methodsEight patients (73.3±4.4 years) with a chronic lacunar stroke (mean interval 3.7 years after the acute event with a range from 2 to 4 years) and residual leg paresis leading to gait disturbance received a guided 5-week training focusing on mobility, endurance, and coordination. Before and afterward, they underwent clinical, neuropsychological, and gait assessments and brain MRI at 3 T including a functional ankle movement paradigm. Sixteen healthy controls (HCs; 68.8±5.4 years) followed the same protocol without intervention.ResultsAfter training, patients had improved in mobility, memory, and delayed recall of memory. While cerebral activations in HC remained completely unaltered, patients showed increased activations in the right precentral gyrus, the right and left superior frontal gyri, and the right frontal lobe, with bipedal ankle movements after training.ConclusionIn this exploratory study of chronic stroke, we found not only significant effects of physical training on mobility but also distinct aspects of cognition already with a small number of highly selected patients. These improvements were paralleled by alterations in cerebral activity possibly reflecting neuronal plasticity. Larger studies including randomization are needed.

Freiburg Neuropathology Case Conference: Multiple Small Ring-Enhancing Lesions in a 75-Year-Old Patient

and/or resection of the lesion. After dural opening, the cortex appeared normal, but swollen. Using neuronavigation to determine the site of cortectomy, the lesion was reached immediately under the surface. It appeared gray, dense, and of rubbery consistence, and some cysts containing CSF-like fluid could be observed. A sample of the solid tissue was removed for instantaneous sectioning. Postoperative blood analysis showed a slightly elevated white blood cell count of 10,020/μl with 87.9 % neutrophils on day 1 and of 11,280/ μl on day 8. Liver transaminases were moderately increased (GOT: 41 U/l, GPT: 49 U/l). After surgery, the patient had an uneventful recovery and was discharged with the residual mild facial paresis to the Department of Internal Medicine for further treatment.

Brachial plexus injury in live related donor hepatectomy: a chart review.

Retrieval of the partial liver graft is a complicated and time-consuming procedure and reported to be associated with brachial plexus injury. We present a case series of brachial plexus injury in live related donor hepatectomy of 95 donors analyzed retrospectively. Seven donors suffered from brachial plexus injuries of varying severity and duration. Out of these, one donor had residual paresis. The reasons could be application of retractors, which may have led to traction and compression above the nerve roots.

Incorporating Robotic-Assisted Telerehabilitation in a Home Program to Improve Arm Function Following Stroke

After stroke, many individuals lack resources to receive the intensive rehabilitation that is thought to improve upper extremity motor function. This case study describes the application of a telerehabilitation intervention using a portable robotic device combined with a home exercise program (HEP) designed to improve upper extremity function. The participant was a 54-year-old man, 22 weeks following right medullary pyramidal ischemic infarct. At baseline, he exhibited residual paresis of the left upper extremity, resulting in impaired motor control consistent with a flexion synergistic pattern, scoring 22 of 66 on the Fugl-Meyer Assessment. The participant completed 85 total hours of training (38 hours of robotic device and 47 hours of HEP) over the 8-week intervention period. The participant demonstrated an improvement of 26 points on the Action Research Arm Test, 5 points on the Functional Ability Scale portion of the Wolf Motor Function Test, and 20 points on the Fugl-Meyer Assessment, all of which surpassed the minimal clinically important difference. Of the 17 tasks of the Wolf Motor Function Test, he demonstrated improvement on 11 of the 15 time-based tasks and both strength measures. The participant reported an overall improvement in his recovery from stroke on the Stroke Impact Scale quality-of-life questionnaire from 40 of 100 to 65 of 100. His score on the Center for Epidemiologic Studies Depression Scale improved by 19 points. This case demonstrates that robotic-assisted therapy paired with an HEP can be successfully delivered within a home environment to a person with stroke. Robotic-assisted therapy may be a feasible and efficacious adjunct to an HEP program to elicit substantial improvements in upper extremity motor function, especially in those persons with stroke who lack access to stroke rehabilitation centers.

Incomplete Horner's syndrome as a presenting sign of fourth ventricle ependymoma

Case reportThe case of 44-year-old male patient with palpebral ptosis and trigeminal neuralgia as presenting sign of fourth ventricle ependymoma is reported. After surgical treatment, the patient developed a residual paresis of the sixth cranial nerve. DiscussionHorner's syndrome occurs due to an alteration of the sympathetic innervations of the eye and adnexa. Some tumors may be the cause, in our case an ependymoma of the fourth ventricle, which onset exceptionally with blepharoptosis and involvement of the ophthalmic division of trigeminal nerve, due to the proximity of these nerve fibers at the brainstem.

Visual cue training to improve walking and turning after stroke: a study protocol for a multi-centre, single blind randomised pilot trial

BackgroundVisual information comprises one of the most salient sources of information used to control walking and the dependence on vision to maintain dynamic stability increases following a stroke. We hypothesize, therefore, that rehabilitation efforts incorporating visual cues may be effective in triggering recovery and adaptability of gait following stroke. This feasibility trial aims to estimate probable recruitment rate, effect size, treatment adherence and response to gait training with visual cues in contrast to conventional overground walking practice following stroke.Methods/designA 3-arm, parallel group, multi-centre, single blind, randomised control feasibility trial will compare overground visual cue training (O-VCT), treadmill visual cue training (T-VCT), and usual care (UC). Participants (n = 60) will be randomly assigned to one of three treatments by a central randomisation centre using computer generated tables to allocate treatment groups. The research assessor will remain blind to allocation. Treatment, delivered by physiotherapists, will be twice weekly for 8 weeks at participating outpatient hospital sites for the O-VCT or UC and in a University setting for T-VCT participants.Individuals with gait impairment due to stroke, with restricted community ambulation (gait speed <0.8m/s), residual lower limb paresis and who are able to take part in repetitive walking practice involving visual cues (i.e., no severe visual impairments, able to walk with minimal assistance and no comorbid medical contraindications for walking practice) will be included.The primary outcomes concerning participant enrolment, recruitment, retention, and health and social care resource use data will be recorded over a recruitment period of 18 months. Secondary outcome measures will be undertaken before randomisation (baseline), after the eight-week intervention (outcome), and at three months (follow-up). Outcome measures will include gait speed and step length symmetry; time and steps taken to complete a 180° turn; assessment of gait adaptability (success rate in target stepping); timed up and go; Fugl-Meyer lower limb motor assessment; Berg balance scale; falls efficacy scale; SF-12; and functional ambulation category.DiscussionParticipation and compliance measured by treatment logs, accrual rate, attrition, and response variation will determine sample sizes for an early phase randomised controlled trial and indicate whether a definitive late phase efficacy trial is justified.Trial registrationClinicaltrials.gov, NCT01600391.

Residual Complaints After Neuralgic Amyotrophy

ObjectiveTo develop recommendations regarding outcome measures and topics to be addressed in rehabilitation for persons with neuralgic amyotrophy (NA), this study explored which functions and activities are related to persisting pain in NA and which questionnaires best capture these factors. DesignA questionnaire-based survey from 2 cross-sectional cohorts, one of patients visiting the neurology outpatient clinic and a cohort seen at a multidisciplinary plexus clinic. SettingTwo tertiary referral clinics based in the Department of Neurology and Rehabilitation from a university medical center provided the data. ParticipantsA referred sample of patients (N=248) with either idiopathic or hereditary NA who fulfilled the criteria for this disorder, in whom the last episode of NA had been at least 6 months ago and included brachial plexus involvement. InterventionsNot applicable. Main Outcome MeasuresTwo custom clinical screening questionnaires were used as well as the Shoulder Rating Questionnaire–Dutch Language Version, the Shoulder Pain and Disability Index (SPADI), the Shoulder Disability Questionnaire (SDQ), and Overall Disability Sum Score. ResultsThe survey confirms the high prevalence of persisting pain and impairments. More than half of the patients were restricted by pain, while in those without pain 60% experienced residual paresis. Correlations show an intimate relation between pain, scapular instability, problems with overhead activities, and increased fatigability. A standard physical therapy approach was ineffective or aggravated symptoms in more than 50%. ConclusionsPain and fatigue are strongly correlated to persisting scapular instability and increased fatigability of the affected muscles in NA. Our results suggest that an integrated rehabilitation approach is needed in which all of these factors are addressed. We further recommend using the SPADI and SDQ in future studies to evaluate the natural course and treatment effects in NA.

Síndrome de Horner incompleto como signo de presentación de ependimoma del cuarto ventrículo

Case reportThe case of 44 year old male patient with palpebral ptosis and trigeminal neuralgia as presenting sign of fourth ventricle ependymoma is reported. After surgical treatment, the patient developed a residual paresis of the sixth cranial nerve. DiscussionHorner's syndrome occurs due to an alteration of the sympathetic innervations of the eye and adnexa. Some tumours may be the cause, in our case an ependymoma of the fourth ventricle, which onset exceptionally with blepharoptosis and involvement of the ophthalmic division of trigeminal nerve, due to the proximity of these nerve fibres at the brainstem.

In Reply

The authors thank Drs. Fuchs-Buder and Schreiber for their interest in our clinical investigation,1and we welcome the opportunity to respond to the questions raised in their Letter to the Editor. We agree that the degree of spontaneous neuromuscular recovery at the time of neostigmine administration has an important effect on the incidence of residual paresis in the postanesthesia care unit. As demonstrated in the investigation of Kim et al. , the median (range) times required to achieve a train-of-four (TOF) ratio of 0.9 after reversal with neostigmine (0.07 mg/kg) were 22.6 (8.3–57.4) min at a TOF count of 2 and 9.7 (5.1–26.4) min at a TOF count of 4.2The relatively common practice of administering an anticholinesterase agent only a few minutes before tracheal extubation, regardless of the TOF count, likely explains the high incidence of residual neuromuscular blockade reported in numerous clinical investigations.3However, our data do not support the conclusion by Drs. Fuchs-Buder and Schreiber “that the difference in symptoms of muscle weakness and improved quality of recovery observed in this study could simply be the consequence of the dose or the timing of the administration of neostigmine.” In fact, no differences in management of reversal of neuromuscular blockade (time or dose) were observed between the acceleromyography and control groups. All patients in the study received a standard dose of neostigmine (50 μg/kg) “at the conclusion of the surgical closure.” The study protocol specifically defined the timing of neostigmine administration to standardize management in both groups and to account for the relatively long time required to achieve adequate recovery of neuromuscular function, even at a TOF count of 4 (10 min).3The protocol also stated that neostigmine should be given at a TOF count of 3–4 and this was achieved in the majority of patients because the median TOF count in both groups was 4 at reversal (only 1 patient of 150 had a TOF count of 0 at this time). Nonetheless, a higher percentage of patients in the acceleromyography group achieved spontaneous recovery to a TOF count of 4 at the time of reversal compared with our control group (80.3%vs. 55.4%, respectively). We believe this was due to more careful management of neuromuscular blockade at the end of surgery in the patients monitored with acceleromyography. In both study groups, dosing of neuromuscular blocking agents was carefully standardized; however, administration of additional neuromuscular blocking agents during the times of the operation not requiring neuromuscular blockade was at the discretion of the anesthesia care team. We hypothesized that acceleromyography monitoring would allow for more accurate titration of neuromuscular blocking agents during this important time period, and our findings supported this hypothesis (i.e. , fewer patients in the acceleromyography group received neuromuscular blocking agents during the last 45 min of the surgical procedure). Thus, our findings suggest that improved spontaneous recovery of neuromuscular function at the time of neostigmine administration in the acceleromyography group resulted in fewer patients with residual muscle weakness in the postanesthesia care unit.It should be noted that the protocol used a simple definition of the TOF count at the time of reversal. As indicated, neostigmine was administered when at least three to four visual responses (“twitches”) to TOF stimulation were observed. Data from the TOF-Watch SX®(Bluestar Enterprises, Omaha, NE) display were not used in the decision process at the time of reversal. We did not attempt to differentiate between a “strong fourth twitch” and a “weak fourth twitch.”In conclusion, we agree that improved spontaneous recovery at the time of reversal resulted in fewer symptoms of muscle weakness in the postanesthesia care unit. Our data suggest that acceleromyography monitoring, by allowing for more rational and accurate management of neuromuscular blockade, resulted in more patients with a TOF count of 4 at the time of reversal and fewer patients with residual paresis after tracheal extubation. Although additional analysis of our data could reveal that patients with higher TOF counts at the time of reversal have fewer symptoms of muscle weakness and improved quality of recovery, such an analysis is beyond the scope of a Letter to the Editor. Additional studies are needed to identify the mechanisms by which acceleromyography monitoring decreases the incidence of residual neuromuscular blockade.