Significant Neurological Recovery Research Articles

AN OVERLAP OF GUILLAIN-BARRÉ SYNDROME, MILLER-FISHER SYNDROME, AND BICKERSTAFF BRAINSTEM ENCEPHALITIS PRESENTING AS CLINICAL BRAIN DEATH, A CASE SERIES

Guillain-Barré Syndrome (GBS), Miller-Fisher Syndrome (MFS), and Bickerstaff Brainstem Encephalitis (BBE) are neuroinflammatory disorders that share common immunopathogenic mechanisms. Although overlapping presentations of these conditions are rare, they pose significant diagnostic challenges, especially when mimicking clinical brain death. Objective: To present a case series of three patients who demonstrated an overlap of GBS, MFS, and BBE, with all patients exhibiting profound neurological impairments, including clinical signs of brain death. Methods: A retrospective review of three cases admitted to the ICU over the last three years was conducted. Detailed clinical profiles, cerebrospinal fluid (CSF) analysis, nerve conduction studies (NCS), and electromyography (EMG) results were reviewed. All patients were treated with intravenous immunoglobulins (IVIG) and therapeutic plasma exchange (TPE). Results: All three patients had a history of preceding infections and were presented with ophthalmoplegia, ataxia, and altered levels of consciousness, progressing to coma. CSF analysis revealed albuminocytological dissociation, and NCS/EMG indicated severe polyneuropathy. Two patients responded positively to IVIG and plasmapheresis, showing significant neurological recovery, while the third patient demonstrated a delayed but spontaneous recovery. All patients eventually achieved full or near-full neurological recovery. Conclusions: This case series highlights the clinical continuum and diagnostic complexity of overlapping GBS, MFS, and BBE, particularly in presentations mimicking brain death. Early recognition and prompt immunomodulatory therapy are crucial in improving patient outcomes, even in cases with severe neurological deficits. Further research is warranted to elucidate pathophysiology and optimize treatment strategies for overlapping neuroinflammatory syndromes.

Efficacy of cement-augmented pedicle screw fixation for osteoporotic mid-thoracic vertebral fractures.

Osteoporotic mid-thoracic vertebral fractures (OmTVF), often result in severe pain, and neurological deficits secondary to cord compression. Cement-augmented pedicle screw (CaPS) fixation with posterior spinal decompression (PSD) offers simultaneous decompression with stabilization of these osteoporotic vertebral fractures. The study involved 32 patients (2022-2023) with T8-T10 osteoporotic vertebral compression fractures resulting in cord compression. All patients underwent CaPS surgery with PSD. Pain reduction was measured using the visual analog scale (VAS), and outcomes with the Oswestry Disability Index, and the American Spinal Injury Association Grades. The local kyphotic angle was also tracked with computed tomography studies performed 1, 3, and 6 months post-operatively. The average pre-operative VAS score was 8.56 mm; this decreased at 1, 3, and 6 months post-operatively to 2.72 mm, 2.03 mm, and 1.44 mm, respectively. In addition, 31 of 32 patients fully recovered within 6 postoperative months. For 31 of 32 patients with T8-T10 osteoporotic vertebral fractures, CaPS fixation with PSD successfully alleviated pain and resulted in significant post-operative neurological recovery.

Pediatric brainstem abscess successfully treated with stereotactic aspiration: illustrative case.

Pediatric brainstem abscesses are rare entities that account for 1% of all brain abscesses and, when diagnosed, constitute a neurosurgical emergency. A previously healthy 11-year-old male presented with several days of worsening headache, confusion, and ataxia. Brain magnetic resonance imaging (MRI) revealed a midbrain and pons lesion. The patient subsequently had a rapid neurological decline with loss of consciousness and brainstem function. Follow-up MRI revealed significant enlargement of the brainstem lesion with extension into the pons, midbrain, and thalamus, with greater concerns for an abscess rather than a tumor or an inflammatory process. He was taken for an emergent stereotactic aspiration of the abscess, and broad-spectrum antibiotics were initiated. He had neurological improvement, which subsequently declined 5 days later with brain MRI revealing an increase in the brainstem abscess, which required a second stereotactic aspiration. After rehabilitation, he made a significant neurological recovery. Pediatric brainstem abscesses are rare pathologies, and a high index of suspicion is needed in patients presenting with a brainstem lesion mimicking tumor but with rapid neurological decline despite no other evidence of infection or infectious/inflammatory markers. Stereotactic aspiration is required for large lesions to target the antibiotic treatment and as an adjunct to broad-spectrum antibiotics.

Treatment and outcomes of patients with metastatic spinal cord compression: a double-center study.

Spinal metastases may only affect the bone tissue and result in spinal instability or may additionally result in epidural compression, leading to neurological deficits. Surgery has emerged as a popular method in treating metastatic epidural spinal cord compression (MESCC) due to the advances in surgical techniques and instrumentation. In this study, we evaluated patients with MESCC regarding neurological status, pain status, and survival rates, and presented our experience managing MESCC. Clinical and radiographic records of 53 patients diagnosed with MESCC between January 2011 and March 2017 were retrospectively evaluated. The study included patients with a pathological diagnosis of primary cancer, those who complained of spinal metastasis, and those who had indications of MESCC on Magnetic Resonance Imaging (MRI). Bone structure and spinal stability were evaluated using assessed Computed Tomography (CT), and metastatic spread was considered using assessed Positron Emission Tomography (PET) in suitable cases. For each patient, the presence of a tumor compressing the spinal cord, age, gender, preoperative, and postoperative American Spinal Injury Association scores (ASIA), Tokuhashi prognostic score (TPS), affected spinal segment, pathological diagnosis, preoperative, and postoperative Visual Analog Scale (VAS), the status of spinal stability, follow-up period, and complications were evaluated. Forty-five patients (82.2% of them were women) underwent surgery with a mean age of 58.29±15.14years. The most frequent type of primary tumor was multiple myeloma (33.9%), followed by lung (24.6%), gastric (7.5%), and prostate (5.7%). The most common site of metastasis was the thoracic region (43.4%), followed by lumbar (24.5%), multiple (24.5%), and cervical (5.7%). The analysis indicated that a significant difference was found between the survival rates of the TPS categories. Common symptoms of MESCC include spinal pain and neurological deficit below the level of the injury. Prompt surgical treatment followed by oncological treatment leads to significant neurological recovery, more prolonged survival, pain relief, and improved quality of life in patients with a short survival time. Oncological treatments, including radiotherapy (RT), should be recommended after surgical treatment.

Intradural Extramedullary IgG4-related Disease of the Dorsal Spine

Spinal intradural extramedullary IgG4-related disease (IgG4-RD) is a rare entity with <20 cases reported in the literature. Here, we discuss one such case of intradural extramedullary IgG4-RD of the dorsal spine who presented to us with paraplegia. Total excision of the lesion was done, following which the patient had significant neurological recovery.

Synergistic therapeutic effects of intracerebral transplantation of human modified bone marrow-derived stromal cells (SB623) and voluntary exercise with running wheel in a rat model of ischemic stroke

BackgroundMesenchymal stromal cell (MSC) transplantation therapy is a promising therapy for stroke patients. In parallel, rehabilitation with physical exercise could ameliorate stroke-induced neurological impairment. In this study, we aimed to clarify whether combination therapy of intracerebral transplantation of human modified bone marrow-derived MSCs, SB623 cells, and voluntary exercise with running wheel (RW) could exert synergistic therapeutic effects on a rat model of ischemic stroke.MethodsWistar rats received right transient middle cerebral artery occlusion (MCAO). Voluntary exercise (Ex) groups were trained in a cage with RW from day 7 before MCAO. SB623 cells (4.0 × 105 cells/5 μl) were stereotactically injected into the right striatum at day 1 after MCAO. Behavioral tests were performed at day 1, 7, and 14 after MCAO using the modified Neurological Severity Score (mNSS) and cylinder test. Rats were euthanized at day 15 after MCAO for mRNA level evaluation of ischemic infarct area, endogenous neurogenesis, angiogenesis, and expression of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF). The rats were randomly assigned to one of the four groups: vehicle, Ex, SB623, and SB623 + Ex groups.ResultsSB623 + Ex group achieved significant neurological recovery in mNSS compared to the vehicle group (p < 0.05). The cerebral infarct area of SB623 + Ex group was significantly decreased compared to those in all other groups (p < 0.05). The number of BrdU/Doublecortin (Dcx) double-positive cells in the subventricular zone (SVZ) and the dentate gyrus (DG), the laminin-positive area in the ischemic boundary zone (IBZ), and the mRNA level of BDNF and VEGF in SB623 + Ex group were significantly increased compared to those in all other groups (p < 0.05).ConclusionsThis study suggests that combination therapy of intracerebral transplantation SB623 cells and voluntary exercise with RW achieves robust neurological recovery and synergistically promotes endogenous neurogenesis and angiogenesis after cerebral ischemia, possibly through a mechanism involving the up-regulation of BDNF and VEGF.

Tenecteplase versus alteplase before mechanical thrombectomy: experience from a US healthcare system undergoing a system-wide transition of primary thrombolytic

BackgroundTenecteplase (TNK) is a genetically modified variant of alteplase (TPA) and has been established as a non-inferior alternative to TPA in acute ischemic stroke (AIS). Whether TNK exerts distinct benefits...

Effects of Acupuncture in the Treatment of Dogs with Neurological Sequels of Distemper Virus

Acupuncture (AP) has been empirically used to relieve post-canine distemper virus (CDV) infection neurological signs in veterinary clinics. This clinical study aimed to investigate the effects of AP combined with electroacupuncture (EA) on neurological function in dogs infected by CDV. Twenty-four CDV-infected dogs with neurological sequelae were recruited to receive weekly AP/EA sections for 24 weeks. Neurological improvements were assessed before each AP/EA session using a modified scoring system. Data were analyzed using the McNemar test, Friedman test, Fisher's exact test, and Kaplan-Meier curves (p < 0.05). Neurological scores improved from seven to 24 weeks after AP/EA treatment compared with pretreatment scores (p < 0.001). Significant improvements were recorded over time for functional limb recovery, cranial nerve deficits, mental status (p = 0.025 - 0.014), and urinary function (p < 0.001). Myoclonus was improved and entirely reversed in 75% and 25% of the dogs, respectively. At the end of treatment, the proportion of dogs with normal proprioception, posture, hopping (p < 0.001), and superficial pain sensation responses (p = 0.004) was greater than pretreatment values. AP/EA therapy promoted significant neurological recovery in CDV-infected dogs and may be considered within the chronic phase of the disease to improve motor and sensory rehabilitation. However, these results are preliminary and must be confirmed by further investigations.

Neurorehabilitation through Hippotherapy on Neurofunctional Sequels of Stroke: Effect on Patients' Functional Independence, Sensorimotor/Cognitive Capacities and Quality of Life, and the Quality of Life of Their Caregivers-A Study Protocol.

Background: Stroke is a high burden illness and the second leading cause of worldwide disability with generally poor recovery rates. Robust benefits of hippotherapy, a novel neurorehabilitation approach, in functional recovery following various severe neurological disabling conditions has been shown. In the present study, we will analyze the effect of a hippotherapy program on the outcome of post-stroke patients in the first year post-stroke. Method: A randomized controlled clinical trial on the effectiveness of hippotherapy (4 weeks/18 weeks hippotherapy/conventional neurorehabilitation) versus conventional neurorehabilitation alone (22 weeks) will be conducted over 48 weeks. In the treated group, one-hour daily hippotherapy sessions will be exclusively conducted during the hippotherapy’s cycles, alternated with periods of conventional neurorehabilitation. A test battery will measure both the functional and psychological outcomes. The primary endpoint will be the patient’s functional independence. The secondary endpoints will measure the sensorimotor function, autonomy, and quality of life, as well as the caregivers’ quality of life. Results and conclusion: Individual brain connectome, life history and personality construct influence the brain’s functional connectivity and are central to developing optimal tailored neurorehabilitation strategies. According to our current practice, hippotherapy allows the enhancement of substantial neuroplastic changes in the injured brain with significant neurological recovery. The protocol aims to confirm those issues. Trial registration in ClinicalTrials.gov NCT04759326 accessed on 19 February 2021.

Impact of timing of surgery on traumatic central cord syndrome without fracture or dislocation

ObjectiveThe management of acute traumatic central cord syndrome (ATCCS) remains controversial. The purpose of this study was to evaluate the impact of timing of surgery on patients with ATCCS without fracture or dislocation. MethodsForty-one patients with ATCCS without fracture or dislocation were identified and divided into three groups described as the conservative treatment group, early surgery group, and delayed surgery group. Clinical outcomes including ASIA Motor Score (AMS), Japanese Orthopaedic Association (JOA) score upon admission and follow-up, change in AMS, and JOA recovery rate were analyzed. Logistic regression analysis was performed to show the correlation between timing of surgery and clinical outcomes. ResultsAll patients received a minimum of 1-year follow-up and showed significant neurological recovery at the final follow-up. No statistical differences in final AMS and JOA scores were observed between the three groups. Patients who underwent early surgery achieved a faster motor recovery at the first 6-months postoperatively compared to conservative treatment(p < 0.01). There was a significant negative correlation between the timing of surgery and the change in AMS (r = -0.41, p = 0.02) in the initial 6-months postoperatively and throughout the follow-up period (r = -0.42, p = 0.02). ConclusionsThe present study indicated that both conservative and surgical treatments can lead to good neurological recovery in patients with ATCCS without fracture or dislocation. Early surgery allowed for rapid early motor recovery compared to conservative treatment. The choice of timing of surgery still requires individualized decision-making.

Spontaneous Spinal Epidural Hematoma Causing Paraparesis in a Patient of Mitral Valve Replacement with Anticoagulant Treatment – A Decision Dilemma

Summary and Background: Spontaneous spinal epidural hematoma (SSEH) is a known occurrence in patients on anticoagulant therapy. There is an increased risk of developing hematoma after the spine surgery if anticoagulation therapy is reinstated. Purpose of Study: The purpose of the study was to find out solution related with perioperative anticoagulant therapy in high-risk cases if patient redevelops hematoma and paraplegia due to continuation of anticoagulant therapy. Case Report: A 30-year-old male presented to us with history of progressive paraparesis. He had history of mitral valve replacement twice followed by cerebrovascular stroke and on regular oral anticoagulant therapy. Magnetic resonance imaging revealed SSEH from C6-T1 level with cord compression. Initial decision was taken to conservatively treat as his coagulation parameters were altered and he was on high-risk for developing thromboembolism related complications if anticoagulant medicines were stopped. However, urgent laminectomy and evacuation of SSEH had to be performed due to rapid worsening of neurology. Postoperatively, patient had significant neurological recovery and anticoagulant therapy reinstated after 12 h of surgery. Patient developed acute paraplegia within 2 hours of anticoagulant therapy due to post-operative hematoma, which was drained out by opening the wound bedside. He regained neurological recovery within 5 min. Anticoagulation therapy was withheld for next 36 hours and reinstated with low-dose intravenous heparin followed by low-molecular weight heparin without any complications. His coagulation parameters and 2-D echo were followed up daily to check cardiac conditions. Patient improved clinically and became self-ambulatory. Conclusion: Post-operative hematoma after spine surgery should be kept in mind in patients who are on anticoagulant treatment. Reinstating anticoagulation treatment in such high-risk patients should be done with lot of caution and initially with low-dose heparin followed by regular anticoagulation therapy. Close observation on neurological status is must to avoid permanent neurological injury. Keywords: Spontaneous spinal epidural hematoma, Anticoagulat treatment, Decision dilemma

A Case of Guillain-Barré Syndrome as the First Presentation of Systemic Lupus Erythematosus

Introduction: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with different clinical manifestations. Acute [resembling Guillain-Barré syndrome (GBS)] or chronic (chronic inflammatory demyelinating polyradiculoneuropathy) inflammatory polyradiculoneuropathy has been reported in rare SLE cases. Case Presentation: We reported a 39-year-old woman that presented with acute peripheral neuropathy, and she was eventually diagnosed with SLE. She developed distal numbness and paraesthesia followed by progressive upper and lower extremity weakness and difficulty in swallowing and speaking. She had a history of flu-like illness three weeks before to symptoms. Conclusions: Progressive upper and lower extremity weakness along with areflexia and electrodiagnostic findings suggested the diagnosis of Guillain-Barré syndrome. Over a month, significant neurological recovery occurred, and the patient's function continued to recover.

SODIUM BICARBONATE USE IN IN-HOSPITAL CARDIAC ARRESTS: A RETROSPECTIVE ANALYSIS

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Sodium Bicarbonate has been used during advanced cardiac life support as one of the supportive measures to fight the build-up of acidosis during prolonged CPR. We aim to investigate the influence of bicarbonate administration on outcomes of cardiopulmonary resuscitation (CPR). METHODS: This was a retrospective observational study in a single medical center and included adult patients who had suffered an in-hospital cardiac arrest between 2016 and 2020. The mean age was 67.2 years (SD 15.5, range 18-95 years), with 109 males (60.2%). We used multivariable logistic regression analysis to evaluate the associations between independent variables and outcomes. The main variable for analysis was the use of bicarbonate during CPR vs no bicarbonate usage. Other factors analyzed were age, gender, comorbidities (heart failure, diabetes, hypertension, COPD, coronary artery disease, and sepsis), as well timing of CPR and total dose of epinephrine used during CPR. Favorable neurological outcome was based on clinical documentation. Kruskal-Wallis rank-sum tests and Pearson's Chi-squared tests were used to calculate p values. RESULTS: 181 patients were included in this analysis. After adjusting for comorbidities, duration of CPR, and confounding medications, the results indicated that sodium bicarbonate usage during CPR was a predictor of poor outcome, there was a significant reduction in the odds of discharge when a patient was given bicarbonate (OR = 0.18 – CI 0.09-0.37, p=<0.0001), such that there is an 82% reduction in the odds of discharge if bicarbonate is given. A likelihood ratio test was used to adjust for different dosing intervals of epinephrine and analyze outcomes for patients who received bicarbonate versus patients who did not, and bicarbonate continued to be a significant predictor of the odds of discharge, again with an 82% reduction in the odds of being discharged if bicarbonate is received (OR = 0.18 – CI 0.09-0.38, p=<0.0001). The odds of neurological recovery at 30 days were reduced by 76% for patients who were given bicarbonate during CPR (OR 0.24, CI 0.11-0.48, p<0.0001). CONCLUSIONS: Sodium Bicarbonate usage during CPR for in-hospital cardiac arrests was seen as a predictor of poor outcomes, including higher in-hospital mortality, and lesser chances of significant neurological recovery. This effect might be partly due to the fact that bicarbonate is used mainly during prolonged CPR situations, which is itself a predictor of poor outcomes. CLINICAL IMPLICATIONS: Sodium bicarbonate usage during CPR was seen to be associated with poorer neurological and mortality outcomes. Larger RCTs are needed to validate these findings. DISCLOSURES: No relevant relationships by Rahul Bollam, source=Web Response No relevant relationships by Waliul Chowdhury, source=Web Response No relevant relationships by Kainat Saleem, source=Web Response No relevant relationships by Syed Arsalan Zaidi, source=Web Response

Cerebral Venous Thrombosis and Its Clinical Diversity

Cerebral venous thrombosis (CVT) is a serious medical condition which is difficult to diagnose because of its wide range of clinical presentations. The symptoms can vary from an isolated headache to coma. Here, we present the case of a 76-year-old female patient with a history of immune thrombocytopenic purpura, arterial hypertension, and pulmonary embolism. The diagnosis of CVT was challenging because the initial form of disease presentation mimicked a transient ischemic attack (transient aphasia and right hemiparesis). Therapeutical decisions were also a challenge because, at the time of the diagnosis, the patient was suffering from severe thrombocytopenia (29 × 109/L), which had to be taken into account. After multidisciplinary discussions, therapeutic subcutaneous enoxaparin was started, resulting in a progressive and significant neurological recovery. In presenting this case, our primary goal is to point out that CVT can be difficult to diagnose because of its wide range of clinical presentations. Headache (a symptom that was never present in this case) is the most frequent complaint, occurring in 90% of cases. Following diagnosis, an etiological study is required.

Surgical therapy for chronic internal carotid artery occlusion: a systematic review and meta-analysis.

Chronic internal carotid artery occlusion (CICAO) significantly increases the risk of recurrent stroke. Given unfavorable outcomes, revascularization procedures are not generally recommended for CICAO. In the last several years, loads of studies reported successful surgical revascularization for CICAO with promising success rate and favorable short-term outcomes. Meanwhile, due to the lack of high-quality evidence, the safety and efficacy of revascularization procedures remain debatable. This systematic review aims to scrutinize current evidence for the applicability of revascularization for CICAO. We also investigated potential predictors of postoperative prognosis. We searched clinical studies on surgical treatment of CICAO on the Medline, Cochrane library, and Embase databases, published from Jan 1990 to Jan 2021. Surgical operation was restricted to bypass surgery, endarterectomy, endovascular therapy, and hybrid surgery. Controlled clinical studies were included for clinical outcomes. Large-sample single-arm studies were supplemented to assess complications and success rate. Co-primary endpoints were technical success rate and neurological function; secondary endpoints were recurrent stroke/cerebrovascular events, complications, and deaths within follow-up. This systematic review has been registered in PROSPERO (CRD42020181250). One RCT and 5 cohort studies with a total of 465 patients were included in this review. Seven single-arm studies were supplemented for assessing success rate and complications. Bypass surgery presented the highest graft patency of 96% and a low incidence of complications, but no benefits on neurological function, recurrent stroke, or deaths. Endovascular therapy (carotid stenting) was characterized by a relatively lower technical success rate, significant neurological function recovery, and nonsignificant reduction of cerebrovascular events and deaths. Hybrid surgery was considered as a potential treatment for CICAO because of a high technical success rate and significant neurological improvement. Endarterectomy is only suitable for short-segment occlusion. Prospective clinical trials should focus on carotid stenting and hybrid surgery for their significant capacity of improving neurologic function and potential capacity of reducing deaths and cerebrovascular events.

Clinical outcome following multisegmental cervical spinal fixation in patients who recovered partially following injury

Objective:The clinical outcome following multilevel stabilization in patients who suffered cervical spinal injury and developed severe neurological deficits and then gradually partially recovered is evaluated. The basis of the surgical concept was that cervical spinal degeneration is a result of single or multilevel spinal instability and that spinal trauma exaggerates the instability.Materials and Methods:During the period 2015–2020, 14 patients who suffered severe cervical spinal injury and could be included in the classification of spinal cord injury without computed tomography evidence of trauma were surgically treated. There were 11 males and 3 females. The ages ranged from 45 to 67 years, average being 53 years. Cervical canal stenoses related to degenerative spinal changes were observed in all patients. All patients suffered severe neurological deficits and within few days or weeks had shown significant but incomplete neurological recovery. The identification of the levels of unstable spinal segments was done on the basis of radiological and clinical parameters and direct observation of spinal instability in adjoining spinal segments. Transarticular fixation was done by Camille's transarticular fixation technique. Using ASIA score, modified JOA score, and Goel Clinical Grading Scale, the clinical course of the patients was monitored.Results:All patients showed recovery in the neurological status. Recovery started in the immediate postoperative period and the improvement progressed during the period of follow-up.Conclusions:Surgery for spinal stabilization can be indicated even in cases that improve in the neurological function.

Sudden Onset Hemiplegia and Neglect: A Case Report of Type A Aortic Dissection Presenting as a Code Stroke

Stanford type A acute aortic dissection with ischemic stroke is a rare yet highly morbid presentation of sudden onset neurological symptoms. We present a case of a 57-year-old African American male brought to the emergency department with a witnessed syncopal episode, abdominal pain, right sided gaze preference, and left side weakness. Upon initiation of the hospital’s “Code Stroke” response protocol, a computed tomography angiogram of the neck incidentally identified Stanford type A aortic dissection with extension into and occlusion of the brachiocephalic artery, occlusion of the right common carotid artery and right internal carotid artery, and dissection flap propagation into the origin of the left common carotid artery. Postoperative magnetic resonance imaging of the brain and the entire spine demonstrated multifocal cerebral infarcts, as well as T10 - L1 spinal infarct. Despite provision of multidisciplinary intensive care unit level of care, the patient failed to demonstrate clinically significant neurological recovery and was transitioned to comfort care after 3 weeks of hospitalization. This case highlights the importance of considering acute aortic dissection as a potential etiology of acute ischemic stroke through the use of computed tomography angiography, as this diagnosis carries profoundly different implications for the consideration of thrombolytic agents and other emergent treatment modalities. J Neurol Res. 2020;10(6):248-252 doi: https://doi.org/10.14740/jnr638

Sudden Onset Hemiplegia and Neglect: A Case Report of Type A Aortic Dissection Presenting as a Code Stroke

Stanford type A acute aortic dissection with ischemic stroke is a rare yet highly morbid presentation of sudden onset neurological symptoms. We present a case of a 57-year-old African American male brought to the emergency department with a witnessed syncopal episode, abdominal pain, right sided gaze preference, and left side weakness. Upon initiation of the hospital’s “Code Stroke” response protocol, a computed tomography angiogram of the neck incidentally identified Stanford type A aortic dissection with extension into and occlusion of the brachiocephalic artery, occlusion of the right common carotid artery and right internal carotid artery, and dissection flap propagation into the origin of the left common carotid artery. Postoperative magnetic resonance imaging of the brain and the entire spine demonstrated multifocal cerebral infarcts, as well as T10 - L1 spinal infarct. Despite provision of multidisciplinary intensive care unit level of care, the patient failed to demonstrate clinically significant neurological recovery and was transitioned to comfort care after 3 weeks of hospitalization. This case highlights the importance of considering acute aortic dissection as a potential etiology of acute ischemic stroke through the use of computed tomography angiography, as this diagnosis carries profoundly different implications for the consideration of thrombolytic agents and other emergent treatment modalities. J Neurol Res. 2020;10(6):248-252 doi: https://doi.org/10.14740/jnr638

Brown-sequard syndrome: A case series from a regional hospital in Nigeria

Brown-Sequard syndrome (BSS) is the constellation of symptoms and signs following hemisection or hemicompression of the spinal cord. The syndrome is an uncommon form of incomplete spinal cord injury with clinical presentation of ipsilateral motor weakness, impaired proprioception and vibratory sensation, with contralateral loss of pain and temperature sensation below the level of the lesion. We report two cases of BSS following penetrating (stab) injuries. The patients were managed non-operatively and they were followed up for 12 and 18 months, respectively, during which they made significant neurologic recovery on the Medical Research Council scale. The objective of this report is to highlight that BSS following trauma can be managed non-operatively with good neurologic outcome in cases where there is no extrinsic compression of the neural tissues.

Window of opportunity for surgical decompression in patients with acute traumatic cervical spinal cord injury.

The objective of this prospective study was to determine the optimal timing for surgical decompression (SD) in patients with acute traumatic cervical spinal cord injury (tSCI) within the first 24 hours of injury. In successive patients with fracture and/or dislocation of the subaxial cervical spine and American Spinal Injury Association Impairment Scale (AIS) grades A-C, receiver operating characteristic curve analysis was used to determine the optimal timing for SD within the first 24 hours of cervical tSCI to obtain a neurological recovery of at least two AIS grades. Multivariate logistic regression was used to model significant neurological recovery with time to SD, degree of spinal canal compromise (SCC), and severity of injury. In this cohort of 64 patients, the optimal timing for SD to obtain a significant neurological improvement was within 4 hours of injury (95% confidence interval 4-9 hours). Increasing the delay from injury to SD or the degree of SCC significantly reduced the likelihood of significant neurological improvement. Due to the strong correlation with SCC, the severity of injury was a marginally significant predictor of neurological recovery. These findings indicate that in patients with acute cervical tSCI and AIS grades A-C, the optimal timing for SD is within the first 4-9 hours of injury, depending on the degree of SCC and the severity of injury. Further studies are required to better understand the interrelationships among the timing of SD, injury severity, and degree of SCC in these patients.