Risk Factors For Neurological Deterioration Research Articles

Evaluation of Post-thrombolytic Events to Determine Appropriate ICU Monitoring Duration for Patients with Ischemic Stroke.

Standard treatment for eligible patients presenting with acute ischemic stroke (AIS) is thrombolysis with tissue plasminogen activators alteplase or tenecteplase. Current guidelines recommend monitoring patients in an intensive care unit (ICU) for 24h after thrombolytic therapy. However, recent studies have questioned the need for prolonged ICU monitoring. This retrospective cohort study aims to identify potential candidates for early transition to a lower level of care by assessing risk factors for neurological deterioration, symptomatic intracranial hemorrhage (sICH), or need for ICU intervention within 24h post-thrombolysis. This retrospective cohort study included adult patients 18years and older with AIS who received thrombolysis. Patients were excluded if they were transferred to another facility, if they were transitioned to comfort care or hospice care within 24h, or if they lacked imaging and National Institutes of Health Stroke Scale (NIHSS) score data. The primary end point was incidence of sICH between 0-12 and 12-24h. Secondary end points included the need for ICU intervention and rates of neurological deterioration. The analysis included 204 patients who received the full dose of alteplase. Among them, ten patients (4.9%) developed sICH, with the majority (n = 7) occurring within 12h post-thrombolysis. Sixty-two patients required ICU interventions within 12h compared with four patients after 12h. Twenty-four patients had neurological deterioration within 12h, and seven patients had neurological deterioration after 12h. Multivariable analysis identified mechanical thrombectomy and increased blood pressure at presentation as predictors of ICU need beyond 12h post-thrombolysis. Our study demonstrates that sICH, neurological deterioration, and need for ICU intervention rarely occur beyond 12h after thrombolytic administration. Patients presenting with blood pressures < 140/90mm Hg, NIHSS scores < 10, and not undergoing mechanical thrombectomy may be best candidates for early de-escalation. Larger prospective studies are needed to more fully evaluate the safety, feasibility, and financial impact of early transition out of the ICU.

Factors Affecting Neurological Deficits in Thoracic Tuberculous Spondylodiscitis.

Thoracic spinal tuberculosis (TB) causes destruction of the spine and compression of the adjacent spinal cord. This study aimed to identify the risk factors for neurological deterioration in patients with thoracic spinal TB to guide decision-making regarding immediate surgery before the onset of weakness. Demographic, clinical, laboratory, and radiologic (x-ray and magnetic resonance imaging) data of 115 patients with active thoracic spinal TB were retrospectively analyzed. Patients with neurological status categorized as Frankel grades A, B, or C (n = 71) were classified as the neurological deficit group, while those with neurological status categorized as Frankel grades D and E (n = 44) constituted the control group. Univariate and multivariate logistic regression analyses were used to predict the risk factors for neurological deficits. The mean patient age was 57.2 years. The most common lesion location was the distal thoracic region (T9-L1; 62.6%). Paradiscal involvement was the most common form of involvement (73%). In the univariate analysis, the significant risk factors associated with neurological worsening were overweight (body mass index [BMI] >25), C-reactive protein level > 20 mg/L, panvertebral involvement, loss of cerebrospinal fluid posterior to the cord, cord signal changes, and canal compromise. The multivariate analysis revealed that only BMI >25 (adjusted OR = 16.18; 95% CI 1.60-163.64; P = 0.018), cord signal changes (adjusted OR = 7.42; 95% CI 1.85-29.74; P = 0.005), and canal encroachment >50% ( adjusted OR = 51.86; 95% CI 5.53-486.24; P = 0.001) were independent risk factors for predicting the risk of neurological deficits. Overweight (BMI >25), cord signal changes, and canal compromise >50% significantly predicted neurological deficits in patients with thoracic spinal TB. Prompt spinal surgery should be considered before progressive worsening of the neurological condition in patients with all of these risk factors. Predictive factors for neurological deficits in thoracic spinal TB were determined. Overweight, cord signal changes, and canal compromise >50% showed predictive value. These factors can help identify patients who require early surgical intervention.

Morphological predictors of neurological deterioration in patients with acute isolated pontine infarct.

To investigate morphological predictors of neurological deterioration (ND) in patients with acute isolated pontine infarct. Acute isolated pontine infarct patients within 7days after onset of stroke symptoms were included retrospectively and classified into ND and non-ND groups. Morphological phenotypes (paramedian pontine infarct [PPI], atypical PPI, small deep infarct, and other types), topographical location, and lesion size were evaluated on axial diffusion-weighted imaging. There were 210 eligible patients, of whom 62 patients had ND (29.5%). The proportion of PPI was significantly higher in ND than that in non-ND (62.9% vs 39.6%). ND occurred more frequently in PPI patients than non-PPI patients (39.8% vs 20.5%). PPI located more frequently in lower pontine (20.4% vs 8.0%) and less in upper pontine (17.3% vs 30.4%, P = 0.028), and had larger ventro-dorsal length (13.8 ± 3.8 vs 9.9 ± 3.1) and width (8.3 ± 2.3 vs 6.2 ± 1.8) than non-PPI patients. The morphological phenotype of PPI was an independent risk factor for ND (OR 4.81, 95%CI 1.54-15.07, P = 0.007) in patients with isolated pontine infarct. The ventro-dorsal length of pontine infarct lesion was associated with ND (OR 1.18, 95%CI 1.01, 1.37, P = 0.034) in PPI patients. The morphological phenotype of PPI was a potential predictor for ND in patients with acute isolated pontine infarct. The ventro-dorsal length of pontine infarct lesion was possibly associated with ND in PPI patients.

Risk factors of deterioration in patients of head injury with non-operative management on first neurosurgical consultation.

In most of the emergency trauma intensive care units (ICUs) of India, neurosurgical opinion is sought for patients presenting with head trauma after earliest possible resuscitation to determine the further line of management. This study aimed to identify common risk factors, leading to neurological deterioration in conservatively managed patients of traumatic brain injury (TBI). This retrospective study analyzed patients admitted with acute TBI and traumatic intracranial hematoma under emergency trauma care ICU who did not require neurosurgical operation within 48 h of trauma. The recorded data were analyzed to determine the predictors of neurological deterioration using univariate and binary logistic regression analysis in SPSS-16 software. Medical records of consecutive 275 patients of acute TBI presenting to the emergency department were studied. One hundred and ninety-three patients were afflicted with mild TBI (70.18%), 49 patients had moderate TBI (17.81%), and 33 had severe TBI (12%). In the outcome, 74.54% of patients were discharged, and operative decision was made on 6.18% of patients and 19.27% died. Severe TBI is the independent predictor of neurological deterioration during their stay in ICU. Progressive hemorrhagic injury (PHI) showed neurological deterioration in 86.5% of patients. Systemic inflammatory response syndrome (SIRS) was present in 93.5% of patients who had deteriorated neurologically. Dyselectrolytemia was the biochemical derangements seen in 24.36% of cases. This study revealed severe TBI, PHI, and SIRS to be strong and independent risk factors of neurological deterioration.

Increased pulsatility index of the basilar artery is a risk factor for neurological deterioration after stroke: a case control study

BackgroundHigher pulsatility of the middle cerebral artery (MCA) is known to be associated with stroke progression. We investigated whether pulsatility index (PI) of the basilar artery (BA) can predict neurological deterioration (ND) after acute cerebral infarction.MethodsA total of 708 consecutive patients with acute ischemic stroke who had undergone transcranial Doppler (TCD) ultrasonography were included. ND was defined as an increase in the National Institutes of Health Stroke Scale scores by two or more points after admission. The patients were categorized into quartiles according to BA PI. Multivariable logistic regression analysis was performed to examine whether BA PI is independently associated with ND.ResultsBA PI was well correlated with the right (n = 474, r2 = 0.573, P < 0.001) by Pearson correlation analysis although MCA PI could not be measured from right MCA (n = 234, 33.05%) and left MCA (n = 252, 35.59%) by TCD owing to insufficient temporal bone window. Multivariable logistic regression analysis including age, sex, cerebral atherosclerosis burden, National Institutes of Health Stroke Scale at admission, and the proportion of patients with current smoking status, hypertension, diabetes mellitus, atrial fibrillation revealed that the higher BA PI (odds ratio, 3.28; confidence interval, 1.07–10.17; P = 0.038) was independently associated with ND.ConclusionsBA PI, which would be identified regardless of temporal window, could predict ND among acute stroke patients.

Risk factors associated with post-operative neurological deterioration in patients with thoracic disc disorders with myelopathy.

Post-operative neurological deterioration (ND) is a severe complication. However, limited literature exists on the ND in thoracic disc disorders with myelopathy (TDM). This study describes the risk factors of neurological deterioration in TDM with instrumentation and fusion. A single-centre review of TDM with instrumentation and fusion during 2006-2019 was performed. Post-operative neurological deterioration was defined as the deterioration of pre-existing neurological function or the appearance of new neurological symptoms. Patients were then grouped into two groups depending on neurological deterioration (ND group) or not (non-ND group). Demographics, radiographic parameters, and surgical characteristics were compared between the two groups. A total of 257 cases were included, and neurological deterioration occurred in 16 (6.23%) cases. Multivariate analysis revealed spinal canal occupancy ratio > 75%, U-shaped compressed spinal cord in axial MRI, calcified herniated disc, anterior approach, and intra-operative blood loss > 1500 mL were associated with ND. Ten patients (62.5%) had complete neurological recovery within six months, and four patients (25%) had progressive neurological function improvement and equal or better than pre-operation within nine months. The rate of neurological deterioration is 6.23%, and a higher spinal canal occupancy ratio, U-shaped compressed spinal cord, calcified herniated disc, anterior approach, and massive intra-operative blood loss were associated with neurological deterioration. Long-term outcomes of neurological deterioration are favourable, and 62.5% of patients experienced complete neurological recovery within six months. Patients with TMD who undergo surgery should be properly informed of the potential risks of neurological deterioration, despite its usually transient nature in most patients.

Effects of end-tidal carbon dioxide levels in patients undergoing direct revascularization for Moyamoya disease and risk factors associated with postoperative complications.

A history of transient ischemic attack, severity of disease, urinary output, hematocrit, hypocapnia, and hypotension during direct revascularization (superficial temporal artery to middle cerebral artery [STA-MCA]) in patients with Moyamoya disease (MMD) may lead to a poor prognosis, however, to our knowledge evidence for end-tidal carbon dioxide (ETCO2) targets is lacking. Within the ranges of standardized treatment, the article was primarily designed to study the risk factors associated with the neurologic outcomes during STA-MCA for MMD especially including ETCO2 ranges and the duration in different groups. The primary goals of this study were to investigate the risk factors for neurologic deterioration and explore the association between ETCO2 ranges and neurologic outcome during general anesthesia for STA-MCA.This retrospective observational study included 56 consecutively adult Moyamoya patients who underwent STA-MCA under general anesthesia between January 2015 and August 2019. ETCO2 was summarized per patient every 5 minutes. Clinical outcome was assessed with clinical presentation, computed tomography findings, magnetic resonance imaging findings, cerebral angiography, and the modified Rankin Scale scores at discharge as main outcome measure. The outcomes were also compared for the duration of surgery, anesthesia, and the length of stay.A total of 56 patients were studied, all patients had comprehensive ETCO2 measurements. The incidence of postoperative complications was 44.6% (25/56). There was no association between age, sex, hypertension, diabetes, smoking history, drinking history, sevoflurane use, invasive arterial blood pressure monitoring, combined encephalomyosynangiosis and postoperative complications. Duration of surgery (P = .04), anesthesia (P = .036), hospital stay (P = .023) were significant correlates of postoperative complications. In the multiple logistic regression model, they were not the significant predictors. The ETCO2 ranges and the length of time in different groups within the current clinical setting was not associated with postoperative complications (P > .05).Within a standardized intraoperative treatment strategy, we found that postoperative complications had no significant correlation with sex, age, hypertension, diabetes, smoking history, drinking history, invasive arterial blood pressure monitoring, combined encephalomyosynangiosis, or sevoflurane use. Further, hypocapnia and hypercapnia during STA-MCA were not found to be associated with postoperative complications in patients with MMD.

Incidence and Risk Factors for Neurological Deterioration in Posterior Corrective Surgeries for Severe Angular Kyphotic Deformities: A 10-Year Institutional Retrospective Study.

Study Design:Retrospective case-control study.Objective:Neurological deficit is one of the dreaded complications of kyphotic deformity correction procedures. There is inconsistency in the reports of neurological outcomes following such procedures and only a few studies have analyzed the risk factors for neurological deficits. We aimed to analyze the factors associated with neurological deterioration in severe kyphotic deformity correction surgeries.Methods:We performed a retrospective study of 121 consecutive surgically treated severe kyphotic deformity cases (49 males, 56 females) at a single institute (May 1st 2008 to May 31st 2018) and analyzed the risk factors for neurological deterioration. The demographic, surgical and clinical details of the patients were obtained by reviewing the medical records.Results:105 included patients were divided into 2 groups: Group A (without neurological deficit) with 92 patients (42 males, 50 females) and Group B (with neurological deficit) with 13 patients (7 males, 6 females) (12.4%). Statistically significant difference between the 2 groups was observed in the preoperative sagittal Cobbs angle (p < 0.0001), operative time (p = 0.003) and the presence of myelopathic signs on neurological examination (p = 0.048) and location of the apex of deformity (p = 0.010) but not in other factors.Conclusions:Preoperative Sagittal Cobbs angle, presence of signs of myelopathy, operative time and location of apex in the distal thoracic region were significantly higher in patients with neurological deterioration as compared to those without neurological deterioration during kyphotic deformity correction surgery. Distal thoracic curve was found to have 4 times more risk of neurological deterioration compared to others.

Neurological deterioration and its risk score in total anterior circulation infarct

ObjectivesSpecific factors and its predictive parameters for neurological deterioration in total anterior circulation infarct (TACI) were not known. Our objective was to determine the risk factors and risk scores for neurological deterioration in TACI. The secondary objective was to determine the effect of antiplatelet therapy in TACI. Patients and MethodsThis was a single-center cohort study. 46 patients with TACI were enrolled and followed up for 30 days, discharged, or death; whichever earlier. The National Institutes of Health Stroke Scale (NIHSS) was performed daily by investigators who are NIHSS certified and radiological findings were confirmed by a certified radiologist. Neurological deterioration was defined by a drop in NIHSS by 2 points or Glasgow Coma Scale (GCS) by 1 point. Clinical, laboratory and radiological variables were evaluated. Significant predictive variables were given a score based on its co-efficient values in multivariate analysis. ResultsLower Alberta stroke program early CT score (ASPECTS) and higher numbers of early computed tomography (CT) sign of middle cerebral artery (MCA) infarct were significant risk factor for neurological deterioration with p < 0.001 (OR: 3.41, 95% CI 1.78–6.51) and p < 0.001 (OR 18.19, 95% CI 3.82–86.55) respectively. A score of 1 assigned for 3 early CT signs of MCA infarct, 2 for 4 early CT signs of MCA infarct, and 1 for ASPECTS < 6. Receiver operating characteristic (ROC) showed a total score of 2 predicted neurological deterioration in TACI (Area under the curve 0.953, with sensitivity and specificity of 78.9% and 93% respectively). ConclusionA simple 2 variables risk score formula was significant in predicting neurological deterioration. Antiplatelet may be recommended for TACI, further study is required.

Predictive factors for neurological deficit in patients with spinal tuberculosis.

Spinal tuberculosis (TB) is a leading cause of damage to the spine and associated neural structures. This study aims to identify the risk factors for neurological deterioration in spinal TB patients to promptly care for the patients before paralysis develops. The demographics, clinical characteristics, laboratory results, and radiographic findings of spinal TB patients were collected between 1993 and 2016. The data were analyzed using logistic regression methods. The predictive factors for neurological deficit were identified. There were 125 spinal TB patients (70 men and 55 women). The average age ± standard deviation was 55.7 ± 2.0 and 52.3 ± 2.4=years, respectively. According to the univariate analysis, the significant risk factors associated with neurological deterioration were signal cord changes, notable Cobb angle (>30°), radiating pain, and epidural abscess. The multivariate analysis revealed that only signal cord change and notable Cobb angle significantly influenced neurological status. The predictive factors for neurological deterioration in spinal TB patients are signal cord change and notable Cobb angle. Surgery should be considered in patients who present with these factors before the development of neurological deterioration.

Predictive factors of neurologic deterioration in patients with spontaneous cerebellar hemorrhage: a retrospective analysis

BackgroundCerebellar hemorrhage is a potentially life-threatening condition and neurologic deterioration during hospitalization could lead to severe disability and poor outcome. Finds out the factors influencing neurologic deterioration during hospitalization is essential for clinical decision-making.MethodsOne hundred fifty-five consecutive patients who suffered a first spontaneous cerebellar hemorrhage (SCH) were evaluated in this 10-year retrospective study. This study aimed to identify potential clinical, radiological and clinical scales risk factors for neurologic deterioration during hospitalization and outcome at discharge.ResultsNeurologic deterioration during hospitalization developed in 17.4% (27/155) of the patient cohort. Obliteration of basal cistern (p≦0.001) and hydrocephalus (p≦0.001) on initial brain computed tomography (CT), median Glasgow Coma Scale (GCS) score at presentation (p≦0.001) and median intracerebral hemorrhage (ICH) score (P≦0.001) on admission were significant factors associated with neurologic deterioration. Stepwise logistic regression analysis showed that patients with obliteration of basal cistern on initial brain CT scan had an odds ratio (OR) of 9.17 (p = 0.002; 95% confidence interval (CI): 0.026 to 0.455) adjusted risk of neurologic deterioration compared with those without obliteration of basal cistern. An increase of 1 point in the ICH score on admission would increase the neurologic deterioration rate by 83.2% (p = 0.010; 95% CI: 1.153 to 2.912). The ROC curves showed that the AUC for ICH score on presentation was 0.719 (p = 0.000; 95% CI: 0.613–0.826) and the cutoff value was 2.5 (sensitivity 80.5% and specificity 73.7%).ConclusionPatients had obliteration of basal cistern on initial brain CT and ICH score greater or equal to 3 at admission implies a greater danger of neurologic deterioration during hospitalization. Cautious clinical assessments and repeated brain images study are mandatory for those high-risk patients to prevent neurologic deterioration during hospitalization.

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.

Risk factors of neurological deterioration in patients with large artery atherosclerosis

Background: In some patients with acute ischemic stroke, neurological deterioration (ND) is observed. Especially in some patients with large artery atherosclerosis (LAA), aggressive medical treatments or endovascular interventions might be helpful to prevent ND. We investigated factors associated with ND in patients with LAA.

Risk Factors of Neurological Deterioration in Patients with Cerebral Infarction due to Large-Artery Atherosclerosis

In some patients with acute ischemic stroke, neurological deterioration (ND) is observed, and it is difficult to predict at the time of admission. Especially in some patients with large-artery atherosclerosis (LAA), aggressive medical treatments and surgical interventions might be helpful to prevent ND. Therefore, we investigated factors associated with ND in patients with LAA. We studied patients with LAA who were admitted to our hospital. We divided them into 2 groups with (group 1) and without deterioration (group 2), and evaluated their medical records, risk factors, and radiological findings, such as number of diffusion-positive lesion and degree of stenosis. Our study population consisted of 171 patients; 71 (41.5%) did and 100 (58.5%) did not suffer deterioration. By univariate analysis, blood pressure (BP), heart rate, National Institutes of Health Stroke Scale (NIHSS) score, number of diffusion-positive lesion, count of red blood cell, high-density lipoprotein, and degree of stenosis differed significantly between the 2 groups. By multivariate analysis, systolic BP (≥170 mm Hg, odds ratio: 7.20, P <.001) was associated with ND. Furthermore, number of diffusion-weighted image (DWI)-positive lesion (≥8), degree of stenosis (>80.0%), and NIHSS score (≥4) were also independent factors associated with ND. High BP, severity of neurological deficit at the time of admission, and radiological findings, such as degree of stenosis and number of DWI-positive lesion, are independently associated with ND in patients with LAA.

Predictors of neurological deterioration during hospitalization: results from the Chinese Intracranial Atherosclerosis (CICAS) Study

Objectives:Neurological deterioration (ND) after ischaemic stroke has been indicated as an independent risk factor for poor outcome. Previous studies have focussed on ND within the first few days after symptom onset, but many patients are likely to experience deterioration outside of this time frame. We aimed to investigate the predictors of ND during hospitalisation.Methods:Data were obtained from the Chinese Intracranial Atherosclerosis (CICAS) Study, and patients who were diagnosed with ischaemic stroke and arrived at the hospital within 72 hours after symptom onset were included in the present study. Neurological deterioration was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score of ≥ 2 points at discharge compared with admission. MR angiography (MRA) and duplex colour Doppler ultrasound were used to document the presence of intracranial or extracranial artery stenosis. Intracranial artery stenosis was defined as a reduction in the artery diameter of ≥ 50% on MRA. Multivariate analyses were conducted to determine the potential predictors of ND during hospitalisation.Results:Of the 1996 patients included in this study, 84 (4.21%) developed ND during hospitalisation. Compared with non-ND patients, ND patients showed higher rates of pneumonia (25.0 vs 9.5%, P < 0.001), urinary infection (7.1 vs 1.2%, P < 0.01), stroke recurrence (14.3 vs 1.9%, P < 0.001), watershed infarct (15.5 vs 5.4%, P = 0.002), intracranial internal carotid artery (ICA) stenosis (11.9 vs 6.0%, P = 0.041), middle cerebral artery (MCA) stenosis (39.3 vs 22.0%, P < 0.001) and basilar artery (BA) stenosis (16.7 vs 7.1%, P = 0.011). Multivariate analysis indicated that watershed infarcts (OR, 2.85; 95% CI, 1.04–7.81), MCA (OR, 2.23; 95% CI, 1.17–4.25) and BA (OR, 2.86; 95% CI, 1.19–6.87) stenosis or occlusion were independent risk factors for ND, as was pneumonia (OR, 3.4; 95% CI, 1.46–7.9).Discussion:Patients with watershed infarcts and MCA or BA stenosis or occlusion should be monitored closely, and various therapeutic strategies should be administered simultaneously to prevent pneumonia during hospitalisation.

Leukoaraiosis Correlates with the Neurologic Deterioration after Small Subcortical Infarction

Patients of small subcortical infarction sometimes have neurologic deterioration (ND), with the risk factors and specific pathogenesis unclear. Small subcortical infarction is often accompanied by other phenotypes of small vessel disease such as leukoaraiosis, which indicates the white matter hyperintensities in the deep or periventricular areas on the fluid-attenuated inversion recovery series of magnetic resonance images and was proved to be associated with stroke in various aspects. In this study, we intended to investigate whether leukoaraiosis was associated with ND after small subcortical infarction, and explore other possible risk factors of ND. Patients with single acute subcortical infarction (<1.5cm in diameter) were recruited consecutively and evaluated everyday. ND was defined as worsening by 2 points or more in the National Institutes Health Stroke Scale (NIHSS) score, or by 1 point or more in the NIHSS score for motor function within 1week after stroke onset. Leukoaraiosis was rated according to the age-related white matter changes scale. Univariate and multivariate analyses were performed to identify the risk factors for ND. Eighty-four of 435 patients (19.31%) had ND. Univariate analysis showed that age, severity of leukoaraiosis, baseline NIHSS score, presence of diabetes, hemoglobin A1c, and total cholesterol levels were all associated with ND. Multivariate analysis further identified that the severity of leukoaraiosis especially leukoaraiosis adjacent to the index infarction, baseline NIHSS score, and diabetes were independently associated with ND. Severity of leukoaraiosis and baseline neurologic deficits, and the presence of diabetes were all independently associated with ND after small subcortical infarction.

Nonoperative Management of Cervical Myelopathy

Systematic review. To conduct a systematic review investigating the evidence of (1) efficacy, effectiveness, and safety of nonoperative treatment of patients with cervical myelopathy; (2) whether the severity of myelopathy affects outcomes of nonoperative treatment; and (3) whether specific activities or minor injuries are associated with neurological deterioration in patients with myelopathy or asymptomatic stenosis being treated nonoperatively. Little is known about the appropriate role of nonoperative treatment in the management of cervical myelopathy, which is typically considered a surgical disorder. A systematic search was conducted in PubMed and the Cochrane Collaboration Library for articles published between January 1, 1956, and November 20, 2012. We included all articles that compared nonoperative treatments or observation with surgery for patients with cervical myelopathy or asymptomatic cervical cord compression to determine their effects on clinical outcomes, including myelopathy scales (Japanese Orthopaedic Association, Nurick), general health scores (36-Item Short Form Health Survey), and pain (neck and arm). Nonoperative treatments included physical therapy, medications, injections, orthoses, and traction. We also searched for articles evaluating the effect of specific activities or minor trauma in neurological outcomes. Case reports and studies with less than 10 patients in the exposure group were excluded. Of 54 citations identified from our search, 5 studies reported in 6 articles met inclusion criteria. In 1 randomized controlled study, there was low evidence that nonoperative treatment may yield equivalent or better outcomes than surgery in those with mild myelopathy. For moderate to severe myelopathy, nonoperative treatment had inferior outcomes versus surgery in 2 cohort studies, despite the fact that surgically treated patients were worse at baseline. There was insufficient evidence to determine whether specific activities or minor trauma is a risk factor for neurological deterioration in those with myelopathy or asymptomatic cord compression. There is a paucity of evidence for nonoperative treatment of cervical myelopathy, and further studies are needed to determine its role more definitively. In particular, for the patient with milder degrees of myelopathy, randomized studies comparing nonoperative with surgical treatment would be particularly helpful, as would trials comparing specific types of nonoperative treatments with the natural history of myelopathy. EVIDENCE-BASED CLINICAL RECOMMENDATIONS: Because myelopathy is known to be a typically progressive disorder and there is little evidence that nonoperative treatment halts or reverses its progression, we recommend not routinely prescribing nonoperative treatment as the primary modality in patients with moderate to severe myelopathy. Low. Strong. If there is a role for nonoperative treatment as a primary treatment modality, it may be in the patient with mild myelopathy. However, it is not clear which specific forms of nonoperative treatment provide any benefit compared with the natural history. If nonoperative treatment is selected, we suggest care be taken to observe for neurological deterioration. Low. Weak. In those with asymptomatic spondylotic cord compression but no clinical myelopathy, the available literature neither supports nor refutes the notion that minor trauma is a risk factor for neurological deterioration. We suggest that patients should be counseled about this uncertainty. Low. Weak. Recommendation 4: In those with a clinical diagnosis of cervical spondylotic myelopathy but no ossification of the posterior longitudinal ligament, the available studies did not specifically address the issue of neurological deterioration secondary to minor trauma. However, in those with underlying ossification of the posterior longitudinal ligament, trauma may be more likely to cause worsening of existing myelopathy or even initiate symptoms in those who were previously asymptomatic. We suggest that patients should be counseled about these possibilities. Low. Weak.

Management and outcome of primary spinal ependymomas: A single center experience from Taiwan

BackgroundSurgical treatment of spinal ependymomas requires careful consideration of the relative risks of neurological worsening from surgery. Our aim was to determine the risk factors of neurological deterioration after surgery for spinal ependymomas. Material and methodsThis 20-year study included 17 patients (seven men and 10 women; 44.65±13.62 years) with histologically confirmed spinal ependymomas. The basic features were reviewed and the functional status was assessed by using the modified McCormick classification. We subdivided the patient population into two groups according to whether neurological deterioration occurred after primary tumor resection (N=5) or not (N=12), and compared their clinical characteristics. ResultsThe average duration of presenting symptoms in the 17 patients was 23.53±21.45 months. Three (17.6%) patients underwent subtotal or partial resection and 14 (82.4%) patients underwent gross total resection. The incidence of neurological deterioration after primary resection of spinal ependymomas was 29.4%. There were five (100%) and two (16.7%) male patients in the neurological-deterioration and no-deterioration groups, respectively (p=0.003). The duration of presenting symptoms was 24 months or over in all the patients with neurological deterioration and five of the 12 patients with improved or stabilized function (p=0.044). ConclusionThe risk associated with surgical resection of spinal ependymomas should not be overlooked because of the significant incidence of neurological deterioration. The male gender and long-standing symptom (≥24 months) are risk factors of postoperative neurological worsening. Early diagnosis and surgery are therefore critical for successful treatment of spinal ependymomas.

Identification of Modifiable and Non-Modifiable Risk Factors for Neurological Deterioration Following Acute Ischemic Stroke (P02.052)

Identification of Modifiable and Non-Modifiable Risk Factors for Neurological Deterioration Following Acute Ischemic Stroke (P02.052)

Identification of Modifiable and Nonmodifiable Risk Factors for Neurologic Deterioration after Acute Ischemic Stroke

Neurologic deterioration (ND) after ischemic stroke has been shown to impact short-term functional outcome and is associated with in-hospital mortality. Patients with acute ischemic stroke who presented between July 2008 and December 2010 were identified and excluded for in-hospital stroke, presentation >48 hours since last seen normal, or unknown time of last seen normal. Clinical and laboratory data, National Institutes of Health Stroke Scale (NIHSS) scores, and episodes of ND (increase in NIHSS score ≥ 2 within a 24-hour period) were investigated. Of the 596 patients screened, 366 were included (median age 65 years; 42.1% female; 65.3% black). Of these, 35.0% experienced ND. Patients with ND were older (69 v 62 years; P < .0001), had more severe strokes (median admission NIHSS score 12 v 5; P < .0001), carotid artery stenosis (27.0% v 16.8%; P = .0275), and coronary artery disease (26.0% v 16.4%; P = .0282) compared to patients without ND. Patients with ND had higher serum glucose on admission than patients without ND (125.5 v 114 mg/dL; P = .0036). After adjusting for crude variables associated with ND, age >65 years, and baseline NIHSS score >14 remained significant independent predictors of ND. In a logistic regression analysis adjusting for age and serum glucose, each 1-point increase in admission NIHSS score was associated with a 7% increase in the odds of ND (odds ratio 1.07; 95% confidence interval 1.04-1.10; P < .0001). Older patients and patients with more severe strokes are more likely to experience ND. Initial stroke severity was the only significant, independent, and modifiable risk factor for ND, amenable to recanalization and reperfusion.