Risk Of Neurological Deterioration Research Articles

Abstract TP37: Prediction of Outcome in Cerebellar Infarction by Diffusion MRI

Background and Purpose — Early identification of patients at risk for neurological deterioration due to edema after stroke remains a challenge. MRI based volumetric assessments of infarct have been shown to predict poor outcome amongst patients with large middle cerebral artery infarcts. However, no such quantitative imaging measure exists to predict outcome following cerebellar stroke. In this study, we tested the hypothesis that volumetric assessment of cerebellar infarcts can provide reliable information for the prediction of neurological deterioration. Methods — We retrospectively identified forty-four consecutive subjects (age 55.2±13) with cerebellar stroke who underwent MRI with DWI (mean 63.7 hours). Subjects were divided into poor (n=13) and good outcomes (n=31). Subjects were classified in the poor outcome group according to at least one of the following criteria: (1) mortality (2) decompressive craniectomy (3) ventriculostomy (4) decrease of consciousness according to item 1a of the NIH stroke scale score (NIHSS). These poor outcomes represent mass effect of the cerebellar infarct. Lesion and cerebellar volume were defined on ADC maps. The ratio of the lesion volume to the whole cerebellum volume was calculated (rVolume). The predictive value of volume and rVolume was determined using ROC analysis. Results — Logistic regression revealed that rVolume was associated with increased risk of poor outcome, even after adjusting for age and NIHSS (χ2 =9.4449, p < 0.0022). The logistic regression model with age, rVolume, and NIHSS achieved an AUC of 0.816 (95% CI: 0.678-0.955), while a regression model with age and NIHSS alone achieved an AUC of 0.711 (95% CI: 0.537-0.885). The difference in AUC between these models was not statistically significant (Z = 0.3816, p = NS). Conclusions — Quantitative measurement of rVolume predicts poor outcome of cerebellar stroke patients, even when controlling for age and NIHSS. Quantitative analysis of diffusion MRI may assist in identification of patients with cerebellar stroke at highest risk of life-threatening edema. Prospective validation is warranted.

Extra and intramedullary anaplastic ependymoma in thoracic spinal cord.

Spinal ependymoma occupies 40-60% of primary spinal cord tumors and has a feature of intramedullary tumor. The tumor most commonly arises from the central canal of the spinal cord, the conus medullaris or the filum terminale and its pathological features are usually benign. Unlike above characteristics, intra and extramedullary ependymomas are reported very rarely and have wide variety of histological features. We present a rare case of spinal anaplastic ependymoma with an accompanied exophytic lesions extramedullary as well. The tumor was poorly delineated between a spinal cord and the extramedullary components in operative view. After we had confirmed the frozen biopsy as anaplastic ependymoma, the remnant mass embedded in the spinal cord was remained because of its unclear resection margin and the risk of neurological deterioration. She underwent radiotherapy with 50.4 Gy, and there were newly developed mass lesions at the lumbosacral region on the MRI, 14 months postoperatively.

Trientine-induced neurological deterioration in a patient with Wilson’s disease

Trientine (triethylenetetramine dihydrochloride) is a copper-chelating agent used to treat patients with Wilson’s disease (WD). It has been considered safe, rarely causing neurological deterioration during initial treatment. We describe a patient diagnosed with WD who became neurologically disabled after treatment with trientine. On a fluid attenuated inversion recovery sequence, brain MRI showed increased areas of high signal intensity compared with initial brain MRI. The patient’s neurological signs partially resolved after cessation of trientine treatment. Our findings suggest that treatment with trientine is associated with a risk of neurological deterioration in patients with WD.

Intravenous immunoglobulin to treat neonatal alloimmune haemolytic disease

Objective: To compare the efficacy of intravenous immunoglobulin (IVIg) and exchange transfusion (EXT) on rhesus haemolytic disease of the newborn (Rh-HDN) and evaluate treatment-related side effects. Methods: Retrospective chart review of two cohorts of newborns with Rh-HDN, treated with (Group 2) or without (Group 1) IVIg. Length of phototherapy, number of EXT, IVIg infusions, intrauterine and top-up red blood cells transfusions, need and permanence of umbilical venous catheter, and length of hospital stay, as well as treatment-related adverse events, were evaluated. Results: Charts of 88 newborns were reviewed (34 in Group 1, 54 in Group 2). Infants in Group 2 received a significantly lower number of EXT, had a lower risk of neurological impairment and needed an umbilical venous catheter for shorter, but required longer phototherapy, longer length of hospital stay, and more top-up transfusions. EXT was associated with a high number of adverse events. Two newborns treated with IVIg developed necrotizing enterocolitis (NEC). Conclusions: IVIg appear as an effective alternative to EXT, reducing the risk of neurological impairment and complications related to EXT. However, side effects of IVIg treatment (higher need of top-up transfusions and longer hospital stay) should be taken into account and the risk of NEC should be carefully monitored during treatment.

Abstract 3479: Prediction of Outcome in Cerebellar Infarction by Diffusion MRI

Background and Purpose - Early identification of patients at risk for neurological deterioration after stroke remains a challenge. MRI based volumetric assessments of infarct have been shown to predict poor outcome amongst patients with large middle cerebral artery infarcts. However, no such quantitative imaging measure exists to predict outcome following cerebellar stroke. In this study, we tested the hypothesis that the volume of cerebellar infarction and its associated apparent diffusion coefficient (ADC), as estimated from diffusion-weighted images (DWI), can provide reliable information for the prediction of neurological deterioration. Methods - We retrospectively identified twenty-eight consecutive patients (age 58.2±13) with cerebellar stroke who underwent MRI (median 40.8 hours) with DWI. Patients were divided into poor (N=7) and good (N=21) outcomes. Patients with poor outcome were defined as those who required posterior fossa decompression or died as a result of their cerebellar infarct. Lesion and cerebellar volume were defined on ADC maps. The ratio of the lesion volume to the whole cerebellum volume was calculated (rVolume) as well as the ratio of the lesion mean ADC to normal cerebellum mean ADC (rADC). The National Institutes of Health Stroke Scale (NIHSS) score, as well as age, sex and race were collected. Binary logistic regression was used to identify predictors of poor outcome. The sensitivity and specificity of rVolume and lesion volume were determined in predicting poor outcome using ROC analysis. Results - Logistic regression analysis revealed that rVolume (p=0.018), lesion volume (p=0.034), NIHSS score (p=0.020) and whole cerebellar ADC value (p=0.043) were significant predictors of poor outcome. The rADC (p=0.073) approached significance. The rVolume (p=0.047) remained a significant predictor of outcome even when controlling for age, NIHSS score, and hours to scan, while a trend towards significance for lesion volume (p=0.072), cerebellar ADC (p=0.069) and rADC (p=0.061) were also observed. ROC analysis revealed that both rVolume as a percentage and lesion volume had a specificity of 95% and a sensitivity of 57% in predicting poor outcome. The respective cut-off values were 30% and 41 cc. Conclusions - Quantitative measurement of rVolume, lesion volume, and cerebellar ADC values are significantly correlated with patient outcomes following cerebellar stroke. Although cerebellar ADC provided additional sensitivity, the rVolume appears to be a strong predictor of outcome when controlling for age, NIHSS score and time to scan. Quantitative analysis of diffusion MRI may assist in identification of patients with cerebellar stroke at highest risk of deterioration. Prospective validation is warranted.

Abstract 58: The Iscore Predicts Efficacy Of Thrombolytic Therapy For Acute Ischemic Stroke

Background: The iScore is a validated tool developed to estimate the risk of death and functional outcomes early after an acute ischemic stroke. It includes demographics, stroke severity and subtype, vascular risk factors, cancer, renal failure, and pre-admission functional status. Limited information is available to predict the clinical response after intravenous thrombolytic therapy (tPA). Objective: To determine the ability of the iScore to predict the clinical response and risk of hemorrhagic transformation after tPA. Methods: We applied the iScore ( www.sorcan.ca/iscore ) to patients presenting with an acute ischemic stroke at 11 stroke centres in Ontario, Canada, between 2003 and 2008, identified from the Registry of the Canadian Stroke Network (RCSN). We compared outcomes between patients receiving and not receiving tPA adjusting for differences in baseline characteristics through matching by propensity scores. Three groups were defined a priori as per the iScore (low risk 180). Outcome Measures: Poor outcome, the primary outcome measure, was defined as disability at discharge or death at 30 days. Secondary outcomes included disability at discharge, neurological deterioration and intracranial hemorrhage (any type and symptomatic). Results: Among 12,686 patients with an acute ischemic stroke, 1696 (13.4%) received intravenous thrombolysis. Overall, 589 tPA patients were matched with 589 non-tPA patients (low iScore risk), 682 tPA were matched with 682 non-tPA patients (medium iScore risk) and 419 tPA patients were matched with 419 non-tPA patients (high iScore risk). There was good matching in all three groups. Higher iScore was associated with poor functional outcome in both the tPA and non-tPA groups (p<0.001). Among those with low and medium iScore risk, tPA use was associated with lower risk of poor outcome (Low iScore RR 0.74; 95%CI 0.67-0.84; medium iScore RR 0.88; 95%CI 0.84-0.93). There was no difference in clinical outcomes between matched patients receiving and not receiving tPA in the highest iScore group (RR 0.97; 95%CI 0.94-1.01). Similar results were observed for disability at discharge and length of stay. The incident risk of neurological deterioration and hemorrhagic transformation (any or symptomatic) increased with the iScore risk ( Figure ). Conclusion: The iScore appears to predict clinical response and risk of hemorrhagic complications after tPA for an acute ischemic stroke. Patients with high iScores may not benefit from tPA and have higher risk of hemorrhagic transformation, though this finding should be validated independently (underway) before clinical use.

Effect of Heparin Following Cervical Spinal Cord Injuries in Rats

Risks of neurological deterioration after heparin administration following cervical spinal cord injury (SCI) in humans are unknown. To elucidate the safety of heparin following cervical SCI and investigate its potential neuroprotectant role. Sixty-two Sprague Dawley adult rats were subjected to mild (0.6 mm), moderate (0.9 mm), or severe (1.2 mm) C7-SCI. At each injury severity, intravenous heparin or saline was administered for 72 hours following SCI. Behavioral tests (Basso, Beattie, Bresnahan scores, Hargreave's) were performed before killing the rats at week 7. Half of the rats were killed at day 3, and the remainder at week 7 after SCI. Immunohistochemistry, Western blot analysis, and axonal retrograde tracing were conducted at both times. Subpial hemorrhage was greater in heparin-treated animals compared with controls at all severities of SCI day 3 after injury. Counterintuitively, intraparencyhmal hemorrhage was minimal in the lesion epicenter following mild SCI in the heparin-treated animals compared with controls. India ink perfusion revealed greater preservation of microcirculation in heparin-treated animals compared with a reduction in control animals. A decrease in spinal cord perfusion correlated directly with an increase in hypoxia-inducible factor-1α expression. There was significant gray matter sparing, but no change in white matter volume after heparin treatment at week 7 in the mild SCI group. Beneficial effects on hemorrhagic volume, axon sparing, and functional recovery following heparin treatment were not observed in the moderate or severe SCI group. Heparin treatment following SCI is safe at all degrees of injury. Heparin decreases platelet aggregation and microvascular occlusion, providing a potential neuroprotective effect following mild SCI.

Language and Motor Mapping During Resection of Brain Arteriovenous Malformations: Indications, Feasibility, and Utility

Microsurgical resection of arteriovenous malformations (AVMs) located in the language and motor cortex is associated with the risk of neurological deterioration, yet electrocortical stimulation mapping has not been widely used. To demonstrate the usefulness of intraoperative mapping with language/motor AVMs. During an 11-year period, mapping was used in 12 of 431 patients (2.8%) undergoing AVM resection (5 patients with language and 7 patients with motor AVMs). Language mapping was performed under awake anesthesia and motor mapping under general anesthesia. Identification of a functional cortex enabled its preservation in 11 patients (92%), guided dissection through overlying sulci down to the nidus in 3 patients (25%), and influenced the extent of resection in 4 patients (33%). Eight patients (67%) had complete resections. Four patients (33%) had incomplete resections, with circumferentially dissected and subtotally disconnected AVMs left in situ, attached to areas of eloquence and with preserved venous drainage. All were subsequently treated with radiosurgery. At follow-up, 6 patients recovered completely, 3 patients were neurologically improved, and 3 patients had new neurological deficits. Indications for intraoperative mapping include preoperative functional imaging that identifies the language/motor cortex adjacent to the AVM; larger AVMs with higher Spetzler-Martin grades; and patients presenting with unruptured AVMs without deficits. Mapping identified the functional cortex, promoted careful tissue handling, and preserved function. Mapping may guide dissection to AVMs beneath the cortical surface, and it may impact the decision to resect the AVM completely. More conservative, subtotal circumdissections followed by radiosurgery may be an alternative to observation or radiosurgery alone in patients with larger language/motor cortex AVMs.

Management of Acute Stroke Patients With Rapidly Resolving Deficits and Persistent Vascular Occlusion

An estimated 8% to 10% of stroke patients arriving at the emergency department within the time window for thrombolysis and with minor or rapidly resolving deficits (RRDs) are found to have proximal arterial occlusions (PAOs).1,2 The management of these patients, particularly when they are neurologically asymptomatic or have only minimal deficits of perceived negligible functional consequence, is challenging because their outcome is unpredictable. Supporters of thrombolysis argue that modern acute ischemic stroke therapy is based on the premise that recanalization and subsequent reperfusion are essential for the preservation of brain tissue and favorable outcomes and that timely thrombolysis is a better option than waiting for clinical deterioration to occur beyond the therapeutic window. Opponents argue that it is impossible to make asymptomatic patients better and cite “ Primum non nocere. ” Drs Kohrmann and Schellinger provide convincing numbers showing that the risk of neurologic deterioration in patients with minor deficits or RRDs far exceeds that of hemorrhagic complications from thrombolysis and …

Peut-on prédire l’aggravation neurologique des patients traumatisés crâniens mineurs et modérés par le dosage sanguin de la protéine S-100β ?

Patients with moderate traumatic brain injury (TBI) (Glasgow Coma Scale, GCS, 9-13) or minor TBI (GCS 14-15) are at risk for subsequent neurological deterioration. Serum protein S-100 is believed to reflect brain damage following TBI. In patients with normal or minor CT scan abnormalities on admission, we tested whether the determination of serum protein S-100 beta could predict secondary neurological deterioration. Sixty-seven patients with moderate or minor TBI were prospectively studied. Serum samples were collected on admission within 12 hours postinjury to measure serum protein S-100 levels. Neurological outcome was assessed up to seven days after trauma. Secondary neurological deterioration was defined as two points or more decrease from the initial GCS, or any treatment for neurological deterioration. Nine patients had a secondary neurological deterioration after trauma. No differences in serum levels of protein S-100 were found between these patients and those without neurological aggravation (n=58 patients): 0.93 microg/l (0.14-4.85) vs 0.39 microg/l (0.04-6.40), respectively. The proportion of patients with abnormal levels of serum protein S-100 at admission according to two admitted cut-off levels (>0.1 and >0.5 microg/l) was comparable between the two groups of patients. Elevated serum levels of protein S-100 were found in patients with Injury Severity Score (ISS) of more than 16 (n=23 patients): 1.26 microg/l (0.14-6.40) vs 0.22 microg/l (0.04-6.20) in patients with ISS less than 16 (n=44 patients). The dosage of serum protein S-100 on admission failed to predict patients at risk for neurological deterioration after minor or moderate TBI. Extracranial injuries can increase serum protein S-100 levels, then limiting the usefulness of this dosage in this clinical setting.

Indicators of pain in neonates at risk for neurological impairment

This paper is a report of a study to compare the importance and usefulness ratings of physiological and behavioural indicators of pain in neonates at risk for neurological impairment by nurse clinicians and pain researchers. Neonates at risk for neurological impairment have not been systematically included in neonatal pain measure development and how clinicians and researchers view pain indicators in these infants is unknown. Data triangulation was undertaken in three Canadian Neonatal Intensive Care Units using data from: (a) 149 neonates at high, moderate and low risk for neurological impairment, (b) 95 nurse clinicians from the three units where infant data were collected and (c) 14 international pain researchers. Thirteen indicators were assessed following heel lance in neonates and 39 indicators generated from nurse clinicians and pain researchers were assessed for importance and accuracy. Data were collected between 2004 and 2005. Across risk groups, indicators with the highest accuracy for discriminating 'pain' among neonates were: brow bulge (77-83%), eye squeeze (75-84%), nasolabial furrow (79-81%), and total facial expression (78-83%). Correlations between nurse ratings and neonatal accuracy scores ranged from moderate to none (mild risk r = 0.52, P = 0.07; moderate r = 0.43, P = 0.15; high r = -0.12, P = 0.69). Researchers demonstrated a better understanding of the importance of pain indicators (mild risk, r = 0.91, P < 0.001; moderate 0.85, P < 0.001; 0.0002; high r = 0.64, P = 0.019) than nurse clinicians. Facial actions were rated as the most important indicators of neonatal pain. However, as neurological impairment risk increased, physiological indicators were rated more important by nurse clinicians and pain researchers, opposite to pain indicators demonstrated by neonates.

Neonatal seizures in Korea, 1983-2009

Neonatal seizures are the most common and distinctive clinical sign of prenatal and/or neonatal brain disorders. Newborn infants with seizures are at risk of mortality and survivors at risk for neurologic impairment, developmental delay, and subsequent epilepsy. Fifteen reports on neonatal seizures in Korea from 1983 to 2009 were analyzed. A total of 731 neonatal seizure cases were reported. Day of seizure onset, etiology, type of seizures, electroencephalogram findings, and outcomes were analyzed. It is necessary to establish a basic report for a future nationwide study of neonatal seizures.

Cerebrovascular Complications in Patients with Left‐Sided Infective Endocarditis Are Common: A Prospective Study Using Magnetic Resonance Imaging and Neurochemical Brain Damage Markers

Background. @nbsp; Cerebrovascular complications (CVCs) have remained a major therapeutic and prognostic challenge associated with infective endocarditis, and definite risk factors have not been fully elucidated. This prospective study was designed to the evaluate the total incidence of CVC associated with infective endocarditis and major risk factors. Methods. @nbsp; During 2 study periods, from June 1998 through April 2001 and from September 2002 through January 2005, patients were prospectively enrolled in the study regardless of neurological symptoms. Study patients underwent neurological examinations and magnetic resonance imaging of the brain, and cerebrospinal fluid analyses of inflammatory and neurochemical markers of brain damage (neurofilament protein and glial fibrillary acidic protein) were performed. Results. @nbsp; Sixty patients who experienced episodes of left-sided infective endocarditis were evaluated; 35% of these patients experienced a symptomatic CVC. Silent cerebral complications were detected in another 30% of the patients, and the total CVC rate was 65% (95% confidence interval, 58%-72%). Five percent of patients experienced their first neurological symptom after the initiation of antibiotic treatment without prior surgery. No new symptomatic CVCs were detected after 10 days of antibiotic treatment. No neurological deterioration was observed after surgery in patients who were established to have a symptomatic CVC preoperatively. A larger heart valvular vegetation size was a risk factor for both symptomatic and silent CVCs; Staphylococcus aureus etiology conferred a higher risk for symptomatic cerebral complication only. Conclusions. @nbsp; The use of sensitive methods of detection indicates that the incidence of CVC associated with infective endocarditis is high, but the risk for neurological deterioration during cardiac surgery after a CVC is lower than previously assumed. The major mechanism behind cerebral complications associated with infective endocarditis is cerebral embolization, although the dominant neurological symptoms vary considerably.

Changes in physiological and behavioural pain indicators over time in preterm and term infants at risk for neurologic impairment

Background Approximately 10% of infants admitted to a Neonatal Intensive Care Unit (NICU) are at risk for Neurological Impairment (NI). While we have limited knowledge on the influence of NI risk on pain responses, we have no knowledge of how these responses change over time. Objective To compare physiological and behavioural pain responses of infants at three levels of NI risk during the NICU neonatal period (Session 1) and at 6 months of age (Session 2). Design/methods Prospective observational design with 149 preterm and term infants at high (Cohort A, n = 54), moderate (Cohort B, n = 45) and mild (Cohort C, n = 50) risks for NI from 3 Canadian tertiary level NICUs. Infants were observed in the NICU during 3 standardized phases of a heel lance: baseline, stick and return-to-baseline. At 6 months, infants were observed during the same three phases during an intramuscular immunization injection. Physiological (heart rate, oxygen saturation) and behavioural (9 facial actions, cry) responses were continuously recorded. Results A significant interaction of Phase by Session was found with less total facial activity observed during Session 2 (all p values < 0.04). A significant interaction for Session by Cohort was found, showing that infants in Cohort A had significantly more change from baseline-to-stick phase for brow bulge, eye squeeze, nasolabial furrow and open lips between sessions with less facial actions demonstrated at Session 2 (all p < 0.02). There were significantly lower mean and minimum heart rate (all p < 0.02) and higher minimum and maximum oxygen saturation ( p < 0.04) at Session 2. Significantly higher mean and minimum fundamental cry frequencies (pitch) in Cohort B ( p < 0.04) were found in Session 1. Cohort A had significantly longer cry durations, but no significant differences in cry dysphonation. Conclusions Behavioural and physiological infant pain responses were generally diminished at 6 months of age compared to those in the neonatal period with some differences between NI risk groups in cry responses. Future exploration into the explanation for these differences between sessions and cohorts is warranted.

Early Intervention After Minor Stroke or TIA

Recent studies have emphasized that a high risk for neurologic deterioration immediately follows ischemic events that either are transient or leave

Management of Cervical Facet Dislocations

Optimal management of unilateral and bilateral cervical facet fractures remains controversial. This article explores the evaluation and treatment options available, focusing on the controversy surrounding prereduction magnetic resonance imaging (MRI) and the choice of surgical approach. In addition, the authors propose a treatment protocol for cervical facet dislocations. Acute disk herniation and disruption is highly prevalent in traumatic cervical facet injury. Some authors maintain the necessity of prereduction MRI to identify those at risk for further prolapse of a herniated disk during closed reduction maneuvers. Others maintain the risk of neurologic deterioration is small in the appropriate patient. To date, no permanent neurological worsening has ever been documented following a closed cervical spine reduction in an awake, cooperative patient. The need for open internal fixation following reduction is widely accepted; however, surgical treatment options are diverse and include anterior, posterior, and combined approaches. Closed reduction of cervical facet dislocations without baseline MRI is appropriate in the awake, cooperative patient. Postreduction MRI is essential in identifying herniated disks and tailoring a surgical approach. An anterior approach is classically employed with a concurrent disk herniation, although a combined anterior and posterior approach is sometimes chosen due to the severity of ligamentous disruption associated with bilateral cervical facet dislocations.

Determining behavioural and physiological responses to pain in infants at risk for neurological impairment

Multiple researchers have validated indicators and measures of infant pain. However, infants at risk for neurologic impairment (NI) have been under studied. Therefore, whether their pain responses are similar to those of other infants is unknown. Pain responses to heel lance from 149 neonates (GA > 25–40 weeks) from 3 Canadian Neonatal Intensive Care units at high (Cohort A, n = 54), moderate (Cohort B, n = 45) and low (Cohort C, n = 50) risk for NI were compared in a prospective observational cohort study. A significant Cohort by Phase interaction for total facial action ( F (6, 409) = 3.50, p = 0.0022) and 4 individual facial actions existed; with Cohort C demonstrating the most facial action. A significant Phase effect existed for increased maximum Heart Rate ( F (3, 431) = 58.1, p = 0.001), minimum Heart Rate ( F (3, 431) = 78.7, p = 0.001), maximum Oxygen saturation ( F (3, 425) = 47.6, p = 0.001), and minimum oxygen saturation ( F (3, 425) = 12.2, p = 0.001) with no Cohort differences. Cohort B had significantly higher minimum ( F (2, 79) = 3.71, p = 0.029), and mean ( F (2, 79) = 4.04, p = 0.021) fundamental cry frequencies. A significant Phase effect for low/high frequency Heart Rate Variability (HRV) ratio ( F (2, 216) = 4.97, p = 0.008) was found with the greatest decrease in Cohort A. Significant Cohort by Phase interactions existed for low and high frequency HRV. All infants responded to the most painful phase of the heel lance; however, infants at moderate and highest risk for NI exhibited decreased responses in some indicators.

Prevalence of human immunodeficiency virus–associated cognitive impairment in a group of Hispanic women at risk for neurological impairment

Human immunodeficiency virus (HIV)-associated cognitive impairment, a significant cause of morbidity, affects up to 30% of HIV-infected people. Its prevalence doubled as patients began to live longer after the introduction of highly active retroviral therapy. Women are now one of the fastest growing groups with acquired immunodeficiency syndrome (AIDS) in the United States and Puerto Rico, but relatively little is known about the prevalence and characteristics of cognitive dysfunction in HIV-infected women. In this study the authors investigated its prevalence in a group of HIV-1-seropositive Hispanic women in Puerto Rico. Forty-nine women with a nadir CD4 cell count of < or = 500 cells/mm3 were enrolled. Cognitive impairment was defined according to the American Academy of Neurology criteria for HIV dementia as modified to identify an "asymptomatic cognitively impaired" group. Observed prevalence was compared with prevalence in other populations in United States, Europe, and Australia. Differences in clinical markers and neuropsychological test performance among the cohort stratified by cognitive impairment were tested. Cognitive impairment was observed in 77.6% (38/49) of cases; asymptomatic cognitive impairment in 32.7% (16/49); minor cognitive motor disorders in 16.3% (8/49); and HIV-associated dementia (HAD) in 28.6% (14/49). Cognitive impairment did not correlate with age, CD4 cell count, viral load, or treatment modality. The cross-sectional prevalence of HIV-associated cognitive impairment was 77.6% (28.6% for HAD). These findings should enhance awareness of the prevalence of HIV-associated cognitive impairment, both clinically apparent and "asymptomatic," in Hispanic women and lead to improvements in areas such as education and compliance and to reevaluation of treatment interventions.

Model for end-stage liver disease (MELD) exception guidelines: Results and recommendations from the MELD exception study group and conference (MESSAGE) for the approval of patients who need liver transplantation with diseases not considered by the standard MELD formula

Richard B. Freeman Jr., Robert G. Gish, Ann Harper, Gary L. Davis, John Vierling, Leslie Lieblein, Goran Klintmalm, Jamie Blazek, Robert Hunter, and Jeffrey Punch Division of Transplantation, Department of Surgery, Tufts–New England Medical Center, Boston, MA; Departments of Medicine and Transplantation and the Division of Hepatology and Complex GI, Physicians Foundation, California Pacific Medical Center, San Francisco, CA; United Network for Organ Sharing, Richmond, VA; Baylor Regional Transplant Institute, Baylor University Medical Center, Dallas, TX; Department of Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA; Ochsner Multi-Organ Transplant Center, New Orleans, LA; and Department of Surgery, University of Michigan, Ann Arbor, MI

Transcranial Doppler to detect on admission patients at risk for neurological deterioration following mild and moderate brain trauma

To investigate the contribution of transcranial Doppler measurements obtained in the emergency room for detecting patients with secondary neurological deterioration after mild or moderate brain trauma. Prospective cohort study in the emergency room in a university teaching hospital. Seventy-eight adult patients admitted to the emergency room after a traumatic brain injury (TBI), including 42 patients with Glasgow Coma Score 14-15 and 36 with 9-13. All patients had transcranial Doppler measurements on both middle cerebral arteries and computed tomography on admission. Neurological outcome was assessed 7 days after trauma. Of the patients included 7 and 10 had secondary neurological deterioration after mild and moderate TBI, respectively. On admission these groups of patients had significantly more injuries on computed tomography using the Trauma Coma Data Bank classification and higher pulsatility index using transcranial Doppler than the patients having no subsequent neurological worsening. Increased pulsatility index after mild or moderate TBI is a reason for concern about the possibility of further neurological deterioration. Computed tomography and Doppler measurements could be combined to detect on admission patients at risk for secondary neurological deterioration in order to improve their initial disposition.