Reversible Neurological Deficit Research Articles

Reperfusion therapy for ischemic stroke without prior neuroimaging

Clinical guidelines and the order of providing care in acute cerebrovascular accidents (CVA) have been developed for standard clinical situations, primarily for patients admitted to medical institutions in an emergency state. However, there are clinical situations when a generally accepted order of therapeutic and diagnostic measures concerning patients with stroke is unjustified and, on the contrary, its implementation threatens life and health of a patient. These situations include ischemic strokes developing intraoperatively during such endovascular interventions as diagnostic cerebral and coronary angiography and transcutaneous neuro- and cardiovascular surgery. Ischemic cerebral events after diagnostic endovascular procedures are relatively rare complications, but their development can lead to unfavorable consequences. Thus, the rates of transient cerebral circulatory disorders after cerebral angiography, a stroke with a reversible neurological deficit, and an ischemic stroke with a persistent neurological deficit are 2.45 %, 0.3 %, and 1.0 % respectively, while total mortality due to acute cerebrovascular pathology is 0.14 %. The rate of cerebral stroke after coronary angiography and percutaneous coronary interventions is up to 0.4 %. Prevention of neurologic complications in diagnostic and surgical transcutaneous interventions is strongly dependant on their correct technique, rational perioperative antithrombotic therapy, and lesser duration of endovascular operations.

Abstract 262: National Trends of 90‐day Readmission Rates and Etiologies among Diabetics following Transient Ischemic Attack

Introduction Transient Ischemic Attack (TIA) is a common neurologic condition characterized by temporary, focal cerebral ischemia that results in reversible neurological deficits without tissue infarction. Type 2 Diabetes Mellitus (T2DM) is a rapidly growing global health problem with increasing prevalence. Currently, data are lacking regarding the trends of 90‐day readmission rates and etiologies among diabetic patients with TIA. Methods We used the Nationwide Readmission Database (NRD) to identify patients with a primary diagnosis of TIA (ICD‐10 code: G45.9) from 2016‐2019 and secondary diagnosis of T2DM. The difference in days between the index admission and the readmission was used to identify patients who were readmitted within 90 days. The primary diagnosis of the readmission was used to identify the etiology of readmission. Data was weighted to allow for representative nationwide estimates. Results We identified 426,549 patients who were admitted with a primary diagnosis of TIA between 2016 and 2019. Of those patients, 35.43% (n=273,993) were diabetic and 64.57% (n=151,112) were non‐diabetic. Diabetics were more likely to be younger (70.43 vs 70.71 years, p<0.001) and male (46.62% vs 42.89%, p<0.001) compared to non‐diabetics. All‐cause 90‐day readmission was higher among diabetics compared to non‐diabetics (15.22% vs 12.03%, p<0.001). Nearly half of 90‐day readmissions occurred within 30 days. There was no significant difference in the rate of 90‐day readmission between 2016 and 2019 (13.19% in 2016 and 12.95% in 2019). Among diabetics, readmitted patients were more likely to be older (71.87 vs 70.18 years, p<0.001) and male (47.96% vs 46.38%, p<0.001). Readmitted diabetics had a higher prevalence of valvular disease (10.12% vs 7.94%), chronic renal failure (33.40% vs 23.98%), coronary artery disease (40.20% vs 32.86%), heart failure (23.88% vs 16.07%), atrial fibrillation (24.02% vs 18.88%), dementia (13.87% vs 11.13%), cancer (4.18% vs 2.44%), and prior VTE (5.24% vs 4.44%) (p<0.001 for all). The most common etiologies of 90‐day readmission among diabetics were cardiovascular (28.98%), neurological (12.92%), and infectious (7.72%). Conclusion Diabetics had higher 90‐day readmission following TIA than non‐diabetics. Cardiovascular conditions were the most common cause of readmission followed by neurological and infectious causes. Further studies are needed to improve risk stratification for diabetic patients following TIA and prevent all‐cause readmission.

Reversible focal neurologic deficits as a complication of diagnostic cerebral angiogram (P14-10.007)

Reversible focal neurologic deficits as a complication of diagnostic cerebral angiogram (P14-10.007)

Symptomatic cerebral vasospasm following posterior fossa hemangioblastoma resection: illustrative case.

BACKGROUNDSymptomatic cerebral vasospasm following posterior fossa intra-axial tumor resection is a rare phenomenon with only seven cases previously reported in the literature. The condition appears distinct to vasospasm following supratentorial tumor resection and extra-axial tumor resection of the posterior fossa. It shares, however, similarities with vasospasm following aneurysmal subarachnoid hemorrhage.OBSERVATIONSThe authors describe their experience with a 23-year-old female who developed delayed symptomatic vasospasm following resection of a left parapontine cerebellar hemangioblastoma. Tumor resection was complicated by rupture of a fragile arterialized vein, resulting in significant hemorrhage. The patient developed several episodes of focal and variably reversible neurological deficit. These clinical signs corresponded with angiographically confirmed vasospasm, which responded to standard therapies for vasospasm post aneurysmal subarachnoid hemorrhage.LESSONSThis case and literature review highlight that symptomatic vasospasm is a rare, potentially highly morbid complication of posterior fossa intra-axial tumor resection. This phenomenon may be related to significant intraoperative or postoperative hemorrhage. Postoperative radiological findings such as high risk modified Fisher scale hemorrhage could alert clinicians to this condition.

Long Cervicothoracolumbal Rigid Bracing Stabilization on Incomplete Spinal Cord Injury of Post-Operated Multi-Focal Upper Cervical-Thoracic Spinal Tuberculosis: A Unique Case Report

Background and aim: Spinal tuberculosis (STB) is a hazardous type of bone tuberculosis that could affect the entire spine, with predilection towards the lower thoracic level. Upper cervical spondylitis occurred only at 0.3 – 1% of all STB cases, but this rare type leads to severe consequences, including tetraplegia, autonomic dysfunction, and respiratory impairment. This case reported long CTLSO rigid external stabilisation reasoning to boost protection whilst recovering tuberculosis despite stable internal stabilisation. Methods: A 34-year-old male came with one year of worsening low-back pain, unintentional weight loss, and gradual loss of power and sensation of both feet within a month. Physical examination showed kyphotic deformity, tenderness, key-muscle-strength 3, and sensory impairment for lower extremities, with no autonomic disturbances. Laboratory works showed chronic ongoing infection. Whole-spine MRI showed multiple spondylodiscitis with multi-focal paravertebral abscesses at C3 – C5, C7 – T3, T9 – T12, L1, severe canal stenosis and anterior segment destruction of T12. Results: The patient was diagnosed with SCI AIS D with a neurological level of L3 secondary to T12 vertebra destruction from STB. He underwent abscess evacuation, debridement, and posterior stabilisation at T10 – L3 and debridement of abscess at C3 – C5 without the need for stabilisation. After procedures, the spine was further stabilised by a CTSLO brace with flexion, extension, lateral flexion, rotation stop. Inward rehabilitation includes incremental mobilisation, upper-limb-extensor-group-strengthening-programme, balance-exercise with ambulation training. Patient discharged with status: ambulate independently with a walker. To date, the patient has returned to work with independent ambulation. Conclusion: Type-III STB was indicated for surgical procedures. Instability of upper cervical prevented patient to performed loadbearing activity thus lowering patient functional outcomes. CTLSO supplementation was given to compensate for 3 lesion sites, the upper cervical, mid-thoracic, and lower-thoracic. For the C3 – C5 lesion, there was no internal stabilisation, so a proper external mode of stabilisation should be given. However, for the thoracic level, CTLSO was given due to (1) incomplete SCI lesion in the absence of deteriorating neurological deficit,c(2) porous nature of STB, and (3) good prognostic recovery of STB with anti-TB medication leading to the reversible neurological deficit.

Prolonged reversible focal neurologic deficits in the elderly with contralateral EEG slowing: a post-ictal, migrainous, or vascular phenomenon? (2253)

Prolonged reversible focal neurologic deficits in the elderly with contralateral EEG slowing: a post-ictal, migrainous, or vascular phenomenon? (2253)

Complications of reverse shoulder arthroplasty: a concise review.

Reverse shoulder arthroplasty is an ideal treatment for glenohumeral dysfunction due to cuff tear arthropathy. As the number of patients treated with reverse shoulder arthroplasty is increasing, the incidence of complications after this procedure also is increasing. The rate of complications in reverse shoulder arthroplasty was reported to be 15%–24%. Recently, the following complications have been reported in order of frequency: periprosthetic infection, dislocation, periprosthetic fracture, neurologic injury, scapular notching, acromion or scapular spine fracture, and aseptic loosening of prosthesis. However, the overall complication rate has varied across studies because of different prosthesis used, improvement of implant and surgical skills, and different definitions of complications. Some authors included complications that affect the clinical outcomes of the surgery, while others reported minor complications that do not affect the clinical outcomes such as minor reversible neurologic deficit or minimal scapular notching. This review article summarizes the processes related to diagnosis and treatment of complications after reverse shoulder arthroplasty with the aim of helping clinicians reduce complications and perform appropriate procedures if/when complications occur.

Redo surgery of carotid arteries in patients with contraindications to carotid angioplasty and stenting

The study was aimed at analysing the in-hospital results of carotid re-endarterectomy and plasty of the zone of reconstruction with a biological patch in patients with haemodynamically significant restenosis and contraindications to carotid angioplasty with stenting. During the period from 2008 to 2019, we operated on a total of 22 patients presenting with carotid restenosis and found to have contraindications to carotid angioplasty with stenting (an extended lesion, unstable neointima, calcification, pronounced tortuosity). Carotid re-endarterectomy was performed according to the classical technique. The time period after the first intervention to regression of pathology amounted to 48.5±21.3 months. All patients with clinical manifestations of angina pectoris were at the preoperative stage subjected to coronarography, as a result of which in one case a hybrid intervention was performed in the scope of percutaneous coronary intervention and carotid endarterectomy. The endpoints included death, myocardial infarction, acute impairment of cerebral circulation, and lesions of craniocerebral nerves. Carotid re-endarterectomy was most often carried out according to the classical technique with plasty of the zone of reconstruction using a xenopericardial patch. Only in 1 case it was required to perform eversion carotid re-endarterectomy due to tortuosity of the internal carotid artery. During the in-hospital postoperative period no lethal outcomes, myocardial infarctions, nor haemorrhagic complications were registered. One patient was found to develop acute impairment of cerebral circulation. The most frequent complication was unilateral laryngeal paresis caused by lesions of craniocerebral nerves (n=3; 13.6%), with reversible neurological deficit. No cases of either thrombosis/restenosis or elevated pressure gradient in the area of implantation of the xenopericardial patch were revealed. The composite endpoint amounted to 18.2% (n=4). The classical carotid re-endarterectomy was not accompanied by cases of thrombosis and restenosis during either the in-hospital or remote period of follow up, however turned out to be associated with a high frequency of the development of complications such as acute impairment of cerebral circulation and lesions of craniocerebral nerves.

Ketamine for empiric treatment of cortical spreading depolarization after subdural hematoma evacuation

BackgroundIt is widely known that some patients surgically treated for subdural hematoma (SDH) experience neurologic deficits not clearly explained by the acute brain injury or known sequelae like seizures. There is increasing evidence that cortical spreading depolarization (CSD) may be the cause. A recent article demonstrated that CSD occurred at a rate of 15 % and was associated with neurological deterioration in a subset of patients following chronic subdural hematoma evacuation. Furthermore, CSD can lead to ischemia leading to worsening neurologic deficits. CSD is usually detected on electrocorticography (ECoG) and needs cortical strip electrode placement with equipment and expertise that may not be readily available. Case DescriptionWe report three cases of patients with subdural hematoma (SDH) not undergoing ECoG in whom CSD was suspected to be the cause of their neurologic deficits post evacuation. Extensive workup including neuroimaging and electroencephalography (EEG) were inconclusive. Patients were subsequently treated with ketamine infusion and had resultant neurological recovery. ConclusionsKetamine infusion can help reverse neurologic deficits in patients with SDH in whom the deficits are not explained by neuroimaging or electrographic seizure. CSD is a known phenomenon that can result in neurological injury and must remain in the differential diagnosis of such patients. Though only limited cases are discussed (n = 3), this small case series provides the basis for conducting clinical trials evaluating the efficacy of ketamine in improving functional outcome in brain-injured patients demonstrating evidence of CSD.

Understanding the effect of non-surgical factors in a transcranial motor-evoked potential alert: A retrospective cohort study

BackgroundIntraoperative neuromonitoring (IONM) is important for detecting neurological dysfunction, allowing for intervention and reversal of neurological deficits before they become permanent. Of the several IONM modalities, transcranial electrical stimulation of motor-evoked potential (TES-MEP) can help monitor the activity in the pyramidal tract. Surgery- and non-surgery-related factors could result in a TES-MEP alert during surgery. Once the alert occurs, the surgeon should immediately intervene to prevent a neurological complication. However, TES-MEP monitoring does not provide sufficient data to identify the non-surgery-related factors. Therefore, this study aimed to identify and describe these factors among TES-MEP alert cases. MethodsIn this multicenter study, data from 1934 patients who underwent various spinal surgeries for spinal deformities, spinal cord tumors, and ossification of the posterior longitudinal ligament of the spine from 2017 to 2019 were collected. A 70% amplitude reduction was set as the TES-MEP alarm threshold. All surgeries with alerts were categorized into true-positive (TP) and false-positive (FP) cases according to the assessment of immediate postoperative neurological deficits. ResultsIn total, TES-MEP alerts were observed in 251 cases during surgery: 62 TP and 189 FP IONM cases. Overall, 158 cases were related to non-surgery-related factors. We observed 22 (35.5%) TP cases and 136 (72%) FP cases, which indicated cases associated with non-surgery-related factors. A significant difference was observed between the two groups regarding factors associated with TES-MEP alerts (p < 0.01). The ratio of TP and FP cases (related to non-surgery-related factors) associated with TES-MEP alerts was 13.9% (22/158 cases) and 86.1% (136/158 cases), respectively. ConclusionsNon-surgery-related factors are proportionally higher in FP than in TP cases. Although the surgeon should examine surgical procedures immediately after a TES-MEP alert, surgical intervention may not always be the best approach according to the results of this study.

Combined treatment of hypervascular spinal tumors. Our experience

Objective – to increase the feasibility and safety of surgical treatment and to achieve better clinical outcome in patients with hypervascular spine tumors by combining managed endovascular embolization followed by surgery.Materials and methods. We enrolled 10 patients (6 men and 4 women, the average age was 57 years) with hypervascular spinal tumors who underwent examination and treatment at SO «Scientific-Practical Center of Endovascular Neuroradiology of NAMS of Ukraine» during the period from 2015 to 2019. Five patients have aggressive vertebral hemangiomas (L1, L2, Th12, Th 7, Th 6) and 5 patients have metastases of renal cell carcinoma of the vertebrae (Th4, Th10, Th12, L3) were included. Medical history and neurological status were evaluated, but in all cases the clinical diagnosis was made according to MRI and spine CT. In addition, all patients underwent selective spinal angiography via transfemoral access at the level of the lesion and in at least two adjacent levels. All patients underwent endovascular embolization of the tumor as the first step and open surgery in the volume of biopsy, decompression, and stabilization of the spine in the second stage. The volume of blood loss in ml was estimated by the anesthesiologist.Results. According to the localization of the lesions, spinal angiography showed a high accumulation of contrast fluid in its structure, compared to surrounding tissues, in all cases. This is evidence of the presence of a hypervascular lesion. All patients underwent the combination treatment – preventive endovascular embolization followed by surgery. In 9 cases embolization was performed 24–36 hours before surgery. Due to the patient’s somatic condition, open surgery was delayed once by 5 days. The total embolization of the tumor vasculature in 7 cases was achieved, with a subtotal embolization in 3 cases. Partial embolization was performed in one case of aggressive hemangioma when the afferent was involved in the blood supply of the spinal artery. Reversible deeper neurologic deficits following embolization in 4 cases was observed. Two patients noticed the reduction of the pain immediately after embolization. Mean intraoperative blood loss was 500 ml during the second stage of treatment. Blood loss was 600 ml in the case of delayed surgery. In all cases, the control of bleeding didn’t interrupt adequate decompression and transpedicular stabilization if it was required, and none of the surgical stages were delayed or canceled because of bleeding. Residual bleeding persisted from the venous system and tumor-related tissues.Conclusions. Preoperative embolization of hypervascularized tumors is a safe and effective method to reduce perioperative hemorrhage, which in turn leads to the reduction of the duration of surgery, improves the visualization of the surgical field, allows the performance of all steps of open surgery and achieve a positive clinical result. The mean blood loss was lower compared to procedures without preoperative embolization, according to published papers on surgery of hypervascular spinal tumors. Embolic agents (mixture of Histoacryl and Lipiodol and polyvinyl alcohol (PVA)) have shown high efficacy to control arterial bleeding, with residual bleeding from the venous system.

Posterior reversible encephalopathy syndrome after massive transfusion in a patient with postpartum vaginal hematoma

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological syndrome characterized by headache, potentially reversible neurological deficits. PRES has been described in various clinical settings, such as severe hypertension, eclampsia, and chemotherapy. Transfusion related PRES are rare. We report a patient with postpartum vaginal hematoma who manifested PRES after massive packed red blood cell transfusion confirmed by brain MRI and clinical features. A 34-year-old woman gravida 1, para 1 admitted for surgery of postpartum vaginal hematoma, rectum repair, sphincter repair. Twelve hours ago, she was delivered. After delivery her uterine contraction was poor and vaginal bleeding was persistent. On admission, her hematocrit was at 27.2%, and her hemoglobin was at 9.0 g/dl. She received 18 packed red blood cell transfusion and 10 packed fresh frozen plasma. Her hematocrit and hemoglobin increased 41.1% and 13.9 g/dl, and platelet increased up to 78,000/ul. After 2 days of the transfusion, she had a left eye ball deviation and 5 min prolonged confusion. Her blood pressure was normal, and no other contributing factors for PRES were found. Brain MRI showed regional T2 signal change in right occipital lobe including cortex, and small signal change in left occipital lobe. In this case, some relation may have existed between late postpartum eclampsia and PRES, but the pathogenesis remains unclear. Although blood transfusion is a common procedure with rare neurological complications, great caution should be taken with anemic patients because a rapid elevation in hemoglobin may precipitate PRES.

Clinical features, outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a case-control study.

The objective of this paper is to investigate the clinical features, outcomes, and risk factors for posterior reversible encephalopathy syndrome (PRES) in systemic lupus erythematosus (SLE). From 2011 to October 2017, SLE patients with PRES were identified from the First Affiliated Hospital of Zhengzhou University, China. Patients presenting with neuropsychiatric lupus hospitalized in the same period were included as controls. Additionally, survival status was acquired via telephone follow-up in March 2018. Thirty episodes of PRES were identified in 29 SLE patients from a total of 7059 SLE patients (prevalence 0.43%). Patients with PRES had a younger age at onset than controls, with seizures more commonly the initial clinical manifestation (80.00% vs 42.37%, p = 0.001). Multiple logistic regression yet again confirmed several known risk factors, including younger age (odds ratio (OR) 1.15 (95% confidence interval (CI) 1.13-1.16)), nephritis (OR 20.74 (18.10-23.75)), history of hypertension (OR 1.17 (1.05-1.31)), SLE Disease Activity Index without neurologic symptoms (SLEDAI-N) score >12 (OR 1.14 (1.11-1.18)) and eclampsia (OR 9.38 (7.84-11.23)). Furthermore, we identified two novel independent risk factors for PRES in SLE: white blood cells >9 × 109/l (OR 2.33 (2.05-2.64)) and heart failure (OR 2.10 (1.18-2.42)). At follow-up, SLE patients with PRES had higher mortality than controls (30.77% vs 8.33%, respectively, p = 0.012). PRES may be a reversible neurological deficit in patients with SLE other than neuropsychiatric lupus. Our results indicate two new risk factors for PRES and that PRES is associated with a higher mortality rate.

Risk Factors Associated with Neurologic Deterioration After Combined Direct and Indirect Revascularization in Patients with Moyamoya Disease on the East Coast of China

Neurologic deterioration is the primary distinctive complication after revascularization surgery in patients with moyamoya disease (MMD). The present study investigated the risk factors for neurologic deterioration after combined direct and indirect revascularization in patients with MMD. A retrospective review of 123 patients with MMD undergoing 138 combined direct and indirect revascularization procedures was performed. Demographics, clinical manifestation, medical history, neurologic deterioration complications, and relevant information of the operation were recorded. There were 25 (18.12%) postoperative neurologic deterioration complications (13 reversible neurologic deficits, 9 infarctions with neurologic sequelae, and 3 hemorrhages). Preoperative multiple symptom episodes and one-staged bilateral revascularization were significantly correlated with postoperative neurologic deterioration complications (P < 0.05 and P < 0.01, respectively). The incidence rate (26.39%) of postoperative neurologic deterioration in ischemic MMDs was significantly greater than hemorrhagic MMDs (7.69%; P < 0.01) In total, 34.78% of patients with transient ischemic attack onset and 22.45% of patients with infarction onset suffered from postoperative neurologic deterioration, and there was no significant difference between them (P > 0.05). Postoperative neurologic deterioration complications had no significant correlation with sex, age at the time of surgery, type of surgical procedure, unilateral MMD or not, interval between the last attack and operation, and history of thyroid disease, hypertension, and autoimmune disease. Preoperative multiple symptom episodes and one-staged bilateral revascularization are risk factors associated with postoperative neurologic deterioration in patients with MMD. Therefore, 2 unilateral revascularization procedures performed successively rather than one-staged bilateral revascularization procedures should be performed in patients with bilateral MMD.

Sagittal splitting of the temporalis muscle for encephalo-myo-synangiosis to prevent ischemic complications due to a swollen temporalis muscle without inhibiting collateral developments in patients with moyamoya disease.

OBJECTIVEEncephalo-myo-synangiosis (EMS) is an effective revascularization procedure for the treatment of moyamoya disease (MMD). However, the temporalis muscle used for EMS sometimes swells and causes ischemic complications by compressing the underlying brain. This study aimed to elucidate the effect of sagittal splitting (SS) of the muscle for prevention of ischemic complications and its impact on the postoperative development of collateral vessels.METHODSIn this historical case-control study, we analyzed 60 hemispheres in adult patients with MMD who underwent EMS using the temporalis muscle from December 1998 to November 2017. The muscle was divided anteroposteriorly by coronal splitting, and the anterior, posterior, or both parts of the muscle were used for EMS in 17, 4, and 39 hemispheres, respectively. In cases performed after 2006, the muscle was halved by SS, and the medial half was used for EMS to reduce the muscle volume (n = 47). The degree of postoperative muscle swelling was evaluated by measuring the maximum thickness of the muscle on CT scans obtained 3 to 7 days after surgery. The collateral developments of the anterior deep temporal artery (aDTA), posterior deep temporal artery (pDTA), and middle temporal artery (MTA) were assessed using digital subtraction angiography and MR angiography performed 6 months or more after surgery.RESULTSSS significantly reduced the temporalis muscle thickness from 12.1 ± 5.0 mm to 7.1 ± 3.0 mm (p < 0.01). Neurological deterioration due to the swollen temporalis muscle developed in 4 of the 13 hemispheres without SS (cerebral infarction in 1, reversible neurological deficit in 2, and convulsion in 1) but in none with SS. There were no significant differences in the postoperative collateral developments of the aDTA, pDTA, and MTA between hemispheres with and without SS. The MTA more frequently developed in hemispheres with EMS in which the posterior part of the muscle was used (30/37) than those in which this part was not used (4/16) (p < 0.01).CONCLUSIONSSS of the temporalis muscle might prevent neurological deterioration caused by the swollen temporalis muscle by reducing its volume without inhibiting the development of the collateral vessels.

Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST).

Spine immobilization in trauma has remained an integral part of most emergency medical services protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating trauma patients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a practice management guideline. We conducted a Cochrane style systematic review and meta-analysis and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit. A total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with risk ratio [RR], 2.4 (confidence interval [CI], 1.07-5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR, 4.16 (CI, 0.56-30.89), and RR, 1.19 (CI, 0.83-1.70), although the point estimates favored no immobilization. Spine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma. Systematic review with meta-analysis study, level III.

Near-Infrared Spectroscopy Does Not Reliably Detect the Cerebral Status in Adults During Aortic Arch Surgery - A Retrospective Trial

Introduction: To investigate relationship between intraoperative regional oxygen cerebral desaturation (rScO_2) and the incidence of neurological deficit after aortic arch surgery in adult patients. Methods: This study was conducted in a retrospective fashion. 53 patients undergoing aortic arch surgery with antegrade selective cerebral perfusion during deep hypothermic circulatory arrest between 2010 and 2012 were included. ln all patients cerebral monitoring was performed using the near-infrared spectroscopy (NIRS) and a bispectral index electroencephalography (BIS). Cumulative values of rScO_2 decrease ＞ 20% of the baseline level (min%) captured as the area under the curve (rScO_2 AUC) were calculated. Patients were divided in two groups: patients with (N-group) and without (Non-N group) a nonreversible neurological deficit, and patients with (D-group) and without (Non-D group) a reversible neurological deficit. Results: Of 53 patients, 49 (93%) suffered an aortic dissection Stanford Type A/De Bakey Type I and 4 (8%) patients a De Bakey Type II. Six (11%) patients died. Eleven (21%) patients developed a nonreversible (stroke, hemorrhage) and 23 (43%) patients a reversible neurological deficit (postoperative delirium). Postoperative delirium was significantly more frequent in the N-group (91%) compared to the Non-N group (33%). No significant difference was found for absolute rScO_2 values ＜ 50% and for the rScO_2 AUC in both hemispheres between all groups. Conclusion: Regional oxygen cerebral desaturation measured by NIRS appears to be a poor indicator for neurological outcome after aortic arch surgery in adults.

Hypoglycemic Encephalopathy: A Neurologic Manifestation of Hypoglycemia

Case Presentation: An 81-year-old man with insulin-treated type 2 diabetes who had been non-compliant with his insulin therapy was taken to the emergency department with altered consciousness of unknown duration. Emergency medical services were called when he was found unresponsive at home by his friend. Paramedics found him comatose and hypoglycemic on the scene with a blood glucose level (BGL) of 1.1 mmol/L. His BGL normalized following administration of intramuscular glucagon and intravenous dextrose. Despite this, he had no neurologic recovery. No toxic or metabolic causes of his altered conscious state were identified and blood gas analysis did not reveal any evidence of hypoxemia. Computed tomography scan of the brain was unremarkable. He was intubated and was transferred to the intensive care unit. Magnetic resonance imaging (MRI) revealed abnormal diffusion restriction involving the cerebral cortex in multiple locations (Figure 1), with the changes most confluent and pronounced in the right parieto-occipital cortex. These findings were consistent with hypoglycemic encephalopathy. He continued to have no neurologic improvement after 6 days of hospital admission. After discussion with the patient’s family, he was transitioned to comfort care given his poor prognosis. He died on the ninth hospital day. Hypoglycemic encephalopathy is a neurologic manifestation of hypoglycemia. The clinical course of this condition is variable, ranging from completely reversible neurologic deficits to irreversible coma [1,2]. Neuropathological studies have demonstrated that the cerebral cortex, hippocampus and basal ganglia are the commonly affected sites in severe hypoglycemia [2,3]. MRI findings in hypoglycemic encephalopathy include diffusion restriction at characteristic locations [2]. Poor prognostic factors in patients with hypoglycemic encephalopathy may include diffuse and extensive cortical involvement, prolonged and profoundhypoglycemia, normal or higher body temperature, and a low lactic acid level during hypoglycemia [1,2].

Mitochondrial dysfunction is an important cause of neurological deficits in an inflammatory model of multiple sclerosis.

Neuroinflammation can cause major neurological dysfunction, without demyelination, in both multiple sclerosis (MS) and a mouse model of the disease (experimental autoimmune encephalomyelitis; EAE), but the mechanisms remain obscure. Confocal in vivo imaging of the mouse EAE spinal cord reveals that impaired neurological function correlates with the depolarisation of both the axonal mitochondria and the axons themselves. Indeed, the depolarisation parallels the expression of neurological deficit at the onset of disease, and during relapse, improving during remission in conjunction with the deficit. Mitochondrial dysfunction, fragmentation and impaired trafficking were most severe in regions of extravasated perivascular inflammatory cells. The dysfunction at disease onset was accompanied by increased expression of the rate-limiting glycolytic enzyme phosphofructokinase-2 in activated astrocytes, and by selective reduction in spinal mitochondrial complex I activity. The metabolic changes preceded any demyelination or axonal degeneration. We conclude that mitochondrial dysfunction is a major cause of reversible neurological deficits in neuroinflammatory disease, such as MS.

The masaryk hospital extracranial-intracranial bypass study.

Patients with symptomatic internal carotid artery (ICA) occlusion with haemodynamic impairment are at higher risk of ischaemic stroke, and they require treatment. There are two main options: the best medical treatment and an extracranial-intracranial bypass. The aims of this study are to analyse the 30-day and 2-year risk of stroke and death in patients with extracranial-intracranial bypass performed by our department and to compare our results with major published studies. This retrospective study enrolled patients who underwent surgery from 1998 to 2012. Inclusion criteria were the following: (1) radiological diagnosis of symptomatic atherosclerotic internal carotid artery occlusion (AICAO), (2) less than 50% stenosis of a contralateral ICA, (3) transient ischaemic attack (TIA) or ischaemic stroke in the hemispheric territory on an occluded side within 120days and (4) haemodynamic impairment of at least stage I according to transcranial Doppler sonography (TCDS), perfusion CT and SPECT. Patients were followed up in the outpatient department with TCDS and sonography of the contralateral ICA and the anastomosis after 6weeks and every 12months after that. All risks of stroke and death from surgery were recorded throughout the 30days and the following 2years post surgery. From September 1998 to November 2012, 93 patients were selected for bypass surgery. There were 72 men and 21 women in an age range of 33 to 79years (mean 58.9years) and a follow-up range of 13 to 187months (mean 108months). The 30-day risk of stroke and death was 7.5%. It consists of one death, one major ischaemic stroke, two reversible neurological deficits and three TIAs. The 2-year risk of stroke and death was 9.7%. Extracranial-intracranial bypass is an effective treatment of haemodynamic impairment in patients with internal carotid occlusion. Maintaining low-level morbidity and mortality is possible with a dedicated neurovascular team. This is the only way in which we can reduce the risk of stroke and death in patients with bypass compared to patients treated medically.