Transient Neurological Symptoms Research Articles

Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures

Study ObjectiveTo compare isobaric lidocaine and mepivacaine in outpatient arthroscopic surgery. DesignProspective, randomized, double-blinded study. SettingAmbulatory surgery center affiliated with an academic tertiary-care hospital. Patients84 adult, ASA physical status 1, 2, and 3 ambulatory patients, age 18-70 years, undergoing arthroscopic knee surgery. InterventionPatients were randomized to receive a combination spinal-epidural anesthetic using 80 mg of either isobaric 2% mepivacaine or isobaric 2% lidocaine. Patients also received a femoral 3-in-1 block with 0.5% bupivacaine applied to the affected extremity. MeasurementsDemographic data and level and duration of the block were recorded. The use of supplemental epidural anesthesia was noted along with frequency of bradycardia, hypotension, and episodes of nausea and vomiting. Duration of block and times to ambulation and voiding were recorded. Delayed variables, including fatigue, difficulty urinating, back pain, and transient neurologic symptoms (TNS) were obtained. Main ResultsNo demographic differences were noted between groups, and surgical duration was similar. Satisfactory anesthesia was achieved in all cases, with no differences noted in hypotension, bradycardia, nausea, or vomiting. Onset of sensory and motor block was similar. Duration of block before epidural supplementation was 94 ± 21 minutes with lidocaine versus 122 ± 23 minutes for mepivacaine (P < 0.011). Times to ambulation and voiding were longer in patients receiving mepivacaine but did not affect PACU stay. Twenty-four and 48-hour recovery was similar with no TNS symptoms reported. ConclusionNo major differences were noted between lidocaine and mepivacaine spinal anesthesia. Time to ambulation and voiding were longer in patients who received mepivacaine as was time to first dose of epidural catheter. Neither group had TNS symptoms. Lidocaine and mepivacaine are both appropriate spinal anesthetics for ambulatory orthopedic lower extremity procedures.

Abstract 2491: Cerebral Amyloid Angiopathy without Hemorrhagic Stroke: MRI Findings Associated with Transient Focal Symptoms

Background: The clinical presentation of cerebral amyloid angiopathy (CAA) includes not only hemorrhagic stroke, but also diverse syndromes such as transient focal neurologic symptoms, progressive cognitive dysfunction, subacute confusion, and seizures. We performed a systematic analysis of the neuroimaging features of these presentations to help elucidate their underlying pathophysiologies. Methods: We performed a retrospective review of all patients seen at Massachusetts General Hospital from 2000-2011 with 1) diagnosis of probable/definite CAA by Boston criteria, 2) clinical presentation other than hemorrhagic stroke, and 3) available MR images (including T2*-weighted, diffusion-weighted, and FLAIR). Review of clinical data for 44 subjects meeting these criteria (performed blinded to neuroimaging) yielded 3 categories of presentation: transient focal motor, sensory, or language symptoms (n=15; mean±SD age 74.4±8.1), memory/cognitive impairment over months-years (n=15; age 71.2±10.7), and subacute headache, confusion, generalized seizure, or syncope (n=14; age 73.6±9.8). Images were analyzed without knowledge of clinical symptoms for hemorrhagic lesions, acute infarcts, and regional T2-hyperintensities. Results: Superficial siderosis in cortical sulci (Panel A) was present in 10 of 15 (67%) patients presenting with transient focal symptoms versus 7 of 29 (24%) in the other subgroups (p&lt;0.01). Most locations of superficial siderosis corresponded with the localization of the patient’s transient symptoms. Conversely, a pattern of T2-hyperintensities extending to subcortical white matter and overlying cortex (Panel B) was present in 8 of 14 (57%) patients presenting with headache, confusion, or seizure/syncope versus 3 of 30 (10%) in the other subgroups (p&lt;0.005). Conclusions: These results suggest that the underlying trigger for CAA-related transient focal neurologic symptoms may often be superficial siderosis. They also support an association between the alternative presentation of headache, confusion, or seizure/syncope and T2-hyperintensities suggestive of the inflammatory subtype of CAA.

Abstract 3135: ABCD 2 Score Can Triage Transient Ischemic Attack (TIA) Patients for Hospitalization

Introduction: Following TIA, there is an increased risk for ischemic stroke. Admission to the hospital is advocated for observation, rapid performance of diagnostic tests, and potential acute intervention. The American Heart Association (AHA) recommends admission following a TIA for patients with ABCD 2 scores greater than 3. We aimed to determine the relationship between ABCD 2 scores and acute neurologic deterioration (TIA or stroke) during hospitalization. Methods: We reviewed consecutive patients admitted to our institution following a TIA between August 1, 2006 and March 31, 2011. TIA was defined as transient focal neurological symptoms that could be attributed to a specific vascular distribution and lasted &lt; 24 hours. We collected data on demographics, clinical symptoms, duration, risk factors, and in-hospital treatments and outcomes. Results: Of 251 patients (mean age 64 years; 45% male), the median ABCD 2 score was 4. The majority had motor symptoms (58.6%) and/or speech/language symptoms (51.4%). Diffusion-weighted imaging was abnormal in 25.9%. The median length of stay was 2.0 days. Nine patients (3.6%) had recurrent TIAs or strokes during their stay (6 TIAs and 3 strokes). All 9 had ABCD 2 scores &gt; 3 while no neurologic deterioration occurred in patients with lower scores (5.3% vs. 0%, P = 0.061). Diffusion lesion frequency did not differ between groups. A total of 13 patients (5.2%) required acute revascularization for large vessel stenosis (6 intracranial; 7 extracranial carotid); none were in the group with recurrent events while hospitalized. No patient received intravenous or intra-arterial thrombolysis. ABCD 2 score did not discriminate those requiring acute revascularization from those who did not (P = 0.242) Conclusions: Our findings support the AHA recommendation that TIA patients be considered for hospitalization when ABCD 2 scores &gt; 3 based on a 5% risk of in-hospital deterioration. However, interventions to prevent stroke were equally common in those with low or high ABCD 2 scores. Outpatient evaluation should be considered for those with scores ≤ 3, provided that vascular imaging is performed urgently and treatment can be expedited.

Abstract 3071: Automated CT Perfusion Processing For the Evaluation of Transient Ischemic Attack

Introduction: The diagnosis of transient ischemic attack (TIA) can be difficult. We evaluated the yield of automated CT perfusion (CTP) in addition to non contrast head CT and CT angiography for the detection of acute ischemic lesions among TIA patients and compare it with multimodal MRI [diffusion weighted imaging (DWI) and perfusion weighted imaging (PWI)] results. Methods: Consecutive patients with a final diagnosis of transient neurological symptoms secondary to ischemia who underwent acute CT, CTP and CTA were enrolled. A subset of the patients underwent multimodal MRI. Presence of symptomatic stenosis was assessed on CTA by the treating team at the time of patient evaluation. The presence and location of acute ischemic lesions was assessed on: CT, CTP, DWI, and PWI. The rater was blinded to the clinical presentation. The presence of a MR or CT perfusion lesion was assessed using TMax. TMax maps for both CT and MR were automatically generated by RApid processing of PerfusIon and Diffusion (RAPID) software. Results: Thirty-three patients were enrolled: median age was 66 years old (IQR 58-82); median ABCD2 score was 4 (IQR 3-5); median delay from symptom onset to CTP was 4.6 hours (IQR 2-9.6). MRI was performed in 23 (70%) patients after a median delay of 20.4 hours (IQR 8.3-30.6) after symptom onset and 5.5 hours (IQR 3.4-20.8) after CTP. No patient experienced recurrence between CTP and MRI. Non-contrast head CT did not demonstrate any acute ischemic lesions. CTA found 3 symptomatic vessel lesions. CTP revealed a focal ischemic lesion in 11 patients (33%). The lesion location concurred with the presumed symptom side in all but one patient, and with the 3 symptomatic vessel lesions found on CTA. DWI was performed in 23 patients, and was positive in 7 (30%). Three of these patients had a negative early CTP. CTP was positive in 3 patients with subsequent normal DWI. MR perfusion was performed in 17 patients and found an acute ischemic lesion in 8 (47%) of them. Four of these MR PWI positive patients also had a positive CTP. In 3 patients with a negative MR PWI, CTP detected an acute ischemic lesion. At least 1 of the 3 modalities (CTP, DWI, PWI) was positive among 10/17 (59%) of patients. Conclusion: The results of this exploratory study suggest that automatically processed CTP increases the yield of head CT and CTA for the evaluation of TIA patients. In some cases CTP found evidence of transient focal ischemia that was not detected by MRI, in others CTP was negative and DWI or PWI was positive. These findings suggest that CTP and MRI may be complementary techniques to confirm the ischemic nature of transient neurological symptoms.

Selective spinal anesthesia for outpatient transurethral prostatectomy (TURP): randomized controlled comparison of chloroprocaine with lidocaine

This is a study comparing two short-acting local anesthetics lidocaine and 2-chloroprocaine in combination with fentanyl, to provide selective spinal anesthesia for outpatient transurethral resection of the prostate (TURP). In this prospective, randomized double-blind study, selective spinal anesthesia was performed in 40 American Society of Anesthesiologists I-III outpatients undergoing TURP using either 40 mg of chloroprocaine mixed with 12.5 μg of fentanyl (n = 20) or 35 mg of lidocaine mixed with 12.5 μg of fentanyl (n = 20). The primary outcome was duration of spinal block. Secondary outcomes were time to reach T10 (onset), time to maximal level, duration above T10 and lidocaine 3, maximal level of block, and adverse effects. The median (minimum, maximum) onset time was 4 (1, 16) and 3 (2, 10) min for chloroprocaine and lidocaine, respectively. Time to maximal level was 20 (17, 29) and 22 (16, 26) min for chloroprocaine and lidocaine, respectively. Mean maximal level was T7-T8 for both agents. Duration of block above T10 was 54 (28, 88) and 63 (31, 87) min for chloroprocaine and lidocaine, respectively. Duration of block above lidocaine 3 was 93 (56, 218) and 98 (58, 151) min for chloroprocaine and lidocaine, respectively. There was no statistical difference between the two groups with respect to these clinical end points. Four patients in the lidocaine group developed transient neurological symptoms. One patient in the chloroprocaine group developed a cauda equina-like syndrome but recovered fully after several weeks. Selective spinal anesthesia with chloroprocaine and lidocaine for TURP yielded comparable results for clinical characteristics. Further research on transient neurological symptom and cauda equina risk with chloroprocaine is warranted.

The Effect of Needle Type, Duration of Surgery and Position of the Patient on the Risk of Transient Neurologic Symptoms

BackgroundThe incidence of transient neurologic symptoms (TNS) after spinal anesthesia with lidocaine is reported as high as 40%.ObjectivesThis prospective clinical trial was designed to determine the incidence of TNS in patients who underwent spinal anesthesia with two different needles, in two different surgical positions.Patients and MethodsThe present randomized clinical trial was conducted on 250 patients (ASA I-II), who were candidates for surgery in supine or lithotomy positions. According to the needle type (Sprotte or Quincke) and local anesthetics (lidocaine and bupivacaine) all patients were randomly divided into four groups. After performing spinal anesthesia in sitting position, the position was changed into supine or lithotomy, according to surgical procedure. The patients were observed for complications of spinal anesthesia during the first five post-operative days. The primary end-point for this trial was to recognize the incidence of TNS among the four groups. Our secondary objective was to evaluate the effect of patient's position, needle type, and duration of surgery on the development of TNS following spinal anesthesia.ResultsTNS was most commonly observed when lidocaine was used as anesthetic drug (P = 0.003). The impact of needle type, was not significant (P = 0.7). According to multivariate analysis, the duration of surgery was significantly lower in cases suffering from TNS (P = 0.04). Also, the risk of TNS increased following surgeries performed in lithotomy position (P = 0.00).ConclusionsAccording to the results of this clinical study, spinal anesthesia with lidocaine, and the lithotomy position in surgery increased the risk of TNS.

Sudden loss of vision during pregnancy: Migraine with visual aura presenting with quadranopsia

Migraine aura without headache can be easily diagnosed from an appropriate migraine history. However, diagnosis is more difficult with a different migraine pattern, especially during pregnancy. A 32-year-old woman in her 37 week of pregnancy presented with quadranopsia in the upper outer quadrant of the left eye. There were no signs of meningismus, sensory or motor deficits. Visual field examination revealed quadranopsia, which lasted 40 minutes and spontaneously resolved. Subsequently, a typical migraine headache began. Several studies have reported that migraine improves in most women during pregnancy. Migraine headaches start de novo during pregnancy in approximately 10% of cases, and the new-onset migraine is often accompanied by migraine aura. Migraine with aura is one of the most common disorders underlying transient focal neurological symptoms among pregnant women. Emergency physicians should take care about pregnant woman presenting with visual disturbance, and consider migraine as differential diagnosis.

Lateral Transpsoas Fusion: Indications and Outcomes

Spinal fusion historically has been used extensively, and, recently, the lateral transpsoas approach to the thoracic and lumbar spine has become an increasingly common method to achieve fusion. Recent literature on this approach has elucidated its advantage over more traditional anterior and posterior approaches, which include a smaller tissue dissection, potentially lower blood loss, no need for an access surgeon, and a shorter hospital stay. Indications for the procedure have now expanded to include degenerative disc disease, spinal stenosis, degenerative scoliosis, nonunion, trauma, infection, and low-grade spondylolisthesis. Lateral interbody fusion has a similar if not lower rate of complications compared to traditional anterior and posterior approaches to interbody fusion. However, lateral interbody fusion has unique complications that include transient neurologic symptoms, motor deficits, and neural injuries that range from 1 to 60% in the literature. Additional studies are required to further evaluate and monitor the short- and long-term safety, efficacy, outcomes, and complications of lateral transpsoas procedures.

Revival of old local anesthetics for spinal anesthesia in ambulatory surgery

In recent years, several older (first intrathecal use in the 1950s, 1960s, and 1970s) local anesthetics have been investigated as spinal anesthetics in ambulatory surgery because these drugs are claimed to cause less transient neurologic symptoms (TNS) than lidocaine which was the main spinal anesthetic for surgery of short-duration for decades. The review covers the current literature. Several recent reports have dealt with the short-acting chloroprocaine and articaine and the intermediate-duration-acting prilocaine. Mepivacaine, another intermediate-acting drug, was applied in one trial only. Various dosages of these drugs either alone or with a small dose of fentanyl were compared with each other, with lidocaine, or with the currently most commonly used low-dose bupivacaine technique. The recovery from both motor and sensory block was usually reasonably fast. However, occasionally recovery after mepivacaine and prilocaine was prolonged which fits ill in a fast-flow ambulatory setting. TNS cases were very rarely reported. The newest results corroborate (at least for chloroprocaine, articaine, and prilocaine) previous data that these drugs provide reliable and mostly well tolerated spinal blocks associated with an apparently smaller risk for postanesthesic TNS as compared with lidocaine. Further studies are warranted regarding broader indications, possible usefulness of adjuvants, and for the exploration of the side-effect profiles in detail. To what extent the observed revival of these older, rather well characterized local anesthetics leads to a wider use of spinal anesthesia in the ambulatory setting remains to be seen. This is also dependent on various organizational and local traditional factors.

Concomitant Traumatic Spinal Cord and Brachial Plexus Injuries: Do They Affect Outcome?

Commentary Rhee et al. should be congratulated on their effort to describe the prevalence of spinal cord injury in their cohort of patients who were referred to their tertiary care center with brachial plexus injuries. The 12.2% prevalence rate in their study is significantly greater than the 2% to 5% prevalence rate previously reported. Their description of associated findings, such as supraclavicular vascular injury, cervical spine fracture, Horner syndrome, or phrenic nerve dysfunction, will help to define which patients have the greatest risk for having a combination of both injuries. They describe in detail how this may affect the outcomes of treatment in patients with combined injuries. There remains a very important question on this topic, which this paper does not answer. This study cohort contains a very heterogeneous group of spinal cord injuries. The authors take great pains to rigorously classify the nature of the spinal cord injury as definitive, probable, or possible. Yet out of thirty-one patients with combined injuries, only eight had identifiable spinal cord injury patterns. As described, the remaining twenty-three subjects had spinal cord injuries of unclear clinical significance. The authors defined “major” clinical evidence of spinal cord injury as a neurologic deficit such as motor, sensory, or sphincter dysfunction on the basis of the history and/or the physical examination. No distinction was made between patients with transient neurological symptoms at the time of injury versus permanent or prolonged neurological deficit. Of twelve subjects with “major” clinical evidence, five had only neurological symptoms in the extremity affected by the brachial plexus injury, but with imaging findings consistent with spinal cord injury. The authors do not explain how they differentiated the neurological deficit that was related to the spinal cord injury from the neurological deficit that was related to the brachial plexus injury in this subgroup. Another eleven subjects had “minor” clinical findings only, such as upper motor neuron signs on clinical examination, and imaging consistent with spinal cord injury. Out of thirty-one patients with combined injuries, only twenty-two had advanced imaging available; that imaging showed increased T2 signal intensity in the spinal cord in nineteen patients, and epidural or subdural hematoma, or both, in three. The authors discuss the significance of Brown-Séquard syndrome on the reconstruction outcomes of patients with brachial plexus injuries. What is not clear is whether the much more subtle spinal cord injuries described in this paper have any long-term impact on the outcome of treatment for the brachial plexus injury. The authors suggest that the presence of a transient neurological deficit at the time of injury or the presence of isolated upper motor neuron findings with increased signal intensity on magnetic resonance imaging (both scenarios that the authors would have defined as definite or probable spinal cord injuries) may result in worse outcomes at the time of reconstruction some months after injury. Without outcomes data, this supposition is unconvincing. Hopefully, the authors will continue to publish their outcomes data from their impressive clinical experience, which may allow them to answer this critical question.

Imaging of brain ischemia

The extent of the penumbra and the core of an acute ischemic stroke influence, at the given time, the impact of the recanalization of the occluded vessel on the outcome. Research studies have demonstrated that quantitative MR diffusion imaging and, to a lesser extent, CT perfusion (CTP) could provide an acceptable estimation of the size of the core, while perfusion imaging thresholds could outline critically hypoperfused regions. Several software programs now automatically process reliable quantitative diffusion-weighted imaging (DWI) and perfusion maps in real time, making them available for clinical routine. Studies investigating whether acute MRI profile could select patient for acute recanalization after the 4.5 h time window approved for rtPA administration are ongoing. Transient ischemic attack (TIA) is a major risk factor for stroke but its clinical diagnosis is difficult. MRI can confirm the ischemic nature of transient neurological symptoms among 50% of the patients and the presence of an acute diffusion lesion is an independent risk factor for acute stroke. Multimodal imaging of ischemic stroke and TIA provides a tissue-based characterization of the ischemic lesion that is dramatically influencing the diagnosis and the management of the patients.

Stroke: new TIA definition, new anticoagulation, no stenting

It is always amazing to see how many articles are published each month in the field of cerebrovascular disorders. As in many fields of medicine and neurology, unfortunately not all publications have a direct clinical impact. However, the three articles presented in this month’s Journal Club have direct clinical implications in terms of the prognosis after transient neurological symptoms, pharmacotherapy of patients with atrial fibrillation and treatment of patients with intracranial arterial stenosis (primum nihil nocere). Over the last few decades there has been much debate about the definition of transient ischemic attacks. The current definition is based on symptom duration of less than 24 h. This definition was, however, arbitrary. Based on the first article of this month’s journal club on early stroke risk after transient neurological symptoms, it is high time that the definition of this term be modified: a so-called tissue-based definition seems to be more reasonable, in particular in terms of its prognostic value for early stroke after transient neurological symptoms. The second article, which was published in the New England Journal of Medicine, deals with a new anticoagulant, a novel oral direct factor Xa inhibitor, apixaban, which is superior to warfarin in preventing stroke and systemic embolism, causing less bleeding and resulting in lower mortality. This development will definitely have major implications on the treatment of patients with atrial fibrillation. The third article, also published in the New England Journal of Medicine, deals with a study on the comparison of stenting versus aggressive medical therapy for intracranial arterial stenosis. The enrolment in this prospective randomized study had to be stopped because the 30-day rate of stroke or death in the percutaneous transluminal angioplasty and stenting group was almost three times higher than in the medical management group, showing that the conservative treatment is evidently much safer and more effective.

Spinal blocks

SummaryEvery anesthetist should have the expertise to perform lumbar puncture that is the prerequisite to induce spinal anesthesia. Spinal anesthesia is easy and effective technique: small amount of local anesthetic injected in the lumbar cerebrospinal fluid provides highly effective anesthesia, analgesia, and sympathetic and motor block in the lower part of the body. The main limitation of spinal anesthesia is a variable and relatively short duration of the block with a single‐injection of local anesthetic. With appropriate use of adjuvant or combining spinal anesthesia with epidural anesthesia, the analgesic action can be controlled in case of early recovery of initial block or in patients with prolonged procedures. Contraindications are rare. Bleeding disorders and any major dysfunction in coagulation system are rare in children, but spinal anesthesia should not be used in children with local infection or increased intracranial pressure. Children with spinal anesthesia may develop the same adverse effects as has been reported in adults, but in contrast to adults, cardiovascular deterioration is uncommon in children even with high blocks. Most children having surgery with spinal anesthesia need sedation, and in these cases, close monitoring of sufficient respiratory function and protective airway reflexes is necessary. Postdural puncture headache and transient neurological symptoms have been reported also in pediatric patients, and thus, guardians should be provided instructions for follow‐up and contact information if symptoms appear or persist after discharge. Epidural blood patch is effective treatment for prolonged, severe headache, and nonopioid analgesic is often sufficient for transient neurological symptoms.

Early stroke risk

The risk of early stroke after TIA is high. Within 7 days of TIA symptoms, 5% of patients have a stroke and up to 15% of patients have a stroke within 90 days.1 These risk estimates come from large population-based and cohort studies utilizing a classic, albeit arbitrary, definition of TIA based on symptom duration of less than 24 hours. Clinical prediction models such as the ABCD2 score that incorporate age, blood pressure, clinical symptoms, and diabetes to stratify risk in the acute setting were developed and validated using cohorts with classically defined TIA.2 Based on these studies, clinicians are urged to treat TIA as a high-risk condition and practice guidelines support expedited diagnostic evaluation and treatment after TIA to mitigate the risk of early stroke.3 A tissue-based definition of TIA based on the presence or absence of infarction on neuroimaging, rather than duration of symptoms, has recently appeared, with medical society endorsements.4 Brain MRI with diffusion-weighted imaging (DWI) can differentiate between transient neurologic symptoms with or without infarction. Based on the revised definition, there …

Recurrent takotsubo cardiomyopathy in the setting of transient neurological symptoms: a case report

IntroductionFirst described in Japan, takotsubo cardiomyopathy is increasingly becoming recognized worldwide as a cause of sudden and reversible diminished left ventricular function characterized by left apical ballooning and hyperkinesis of the basal segments, often with symptoms mimicking a myocardial infarction. Associated with physical or emotional stress, its exact pathogenesis has not been established, though evidence supports a neurohumoral etiology. Additionally, recurrence of this condition is rare. In this report, we present a rare case of recurrent takotsubo cardiomyopathy in a post-menopausal woman who presented with transient neurological complaints on both occasions.Case presentationWe present a rare case of a 76-year-old Caucasian woman with no history of congestive heart failure who presented to our emergency department twice with transient neurological complaints. On the first occasion, she was found to have transient aphasia which resolved within 24 hours, yet during that period she also developed symptoms of congestive heart failure and was noted to have a new, significantly depressed ejection fraction with apical akinesis and possible apical thrombus. One month after her presentation a repeat echocardiogram revealed complete resolution of all wall motion abnormalities and a return to baseline status. Seven months later she presented with ataxia, was diagnosed with vertebrobasilar insufficiency, and again developed symptoms and echocardiography findings similar to those of her first presentation. Once again, at her one-month follow-up examination, all wall motion abnormalities had completely resolved and her ejection fraction had returned to normal.ConclusionThough the exact etiology of takotsubo cardiomyopathy is unclear, a neurohumoral mechanism has been proposed. Recurrence of this disorder is rare, though it has been reported in patients with structural brain abnormalities. This report is the first to describe recurrent takotsubo cardiomyopathy in a patient with transient neurological symptoms. In our patient, as expected in patients with this condition, complete resolution of all left ventricular abnormalities occurred within a short period of time. It is important for clinicians to be aware of this increasingly recognized syndrome, including its association with recurrence, especially in the clinical setting of neurologic dysfunction.

The King–Devick test and sports-related concussion: Study of a rapid visual screening tool in a collegiate cohort

Objective Concussion, defined as an impulse blow to the head or body resulting in transient neurologic signs or symptoms, has received increasing attention in sports at all levels. The King–Devick (K–D) test is based on the time to perform rapid number naming and captures eye movements and other correlates of suboptimal brain function. In a study of boxers and mixed martial arts (MMA) fighters, the K–D test was shown to have high degrees of test–retest and inter-rater reliability and to be an accurate method for rapidly identifying boxers and mixed martial arts fighters with concussion. We performed a study of the K–D test as a rapid sideline screening tool in collegiate athletes to determine the effect of concussion on K–D scores compared to a pre-season baseline. Methods In this longitudinal study, athletes from the University of Pennsylvania varsity football, sprint football, and women's and men's soccer and basketball teams underwent baseline K–D testing prior to the start of the 2010–11 playing season. Post-season testing was also performed. For athletes who had concussions during the season, K–D testing was administered immediately on the sidelines and changes in score from baseline were determined. Results Among 219 athletes tested at baseline, post-season K–D scores were lower (better) than the best pre-season scores (35.1 vs. 37.9 s, P = 0.03, Wilcoxon signed-rank test), reflecting mild learning effects in the absence of concussion. For the 10 athletes who had concussions, K–D testing on the sidelines showed significant worsening from baseline (46.9 vs. 37.0 s, P = 0.009), with all except one athlete demonstrating worsening from baseline (median 5.9 s). Conclusion This study of collegiate athletes provides initial evidence in support of the K–D test as a strong candidate rapid sideline visual screening tool for concussion. Data show worsening of scores following concussion, and ongoing follow-up in this study with additional concussion events and different athlete populations will further examine the effectiveness of the K–D test.

Imaging Predictors of Outcome in Patients with Transient Ischemic Attacks and Minor Stroke: Review of published data from the VISION study

Urgent neuroimaging has become an integral part of the care of patients with ischemic stroke. In patients with transient ischemic attack (TIA) and minor stroke (MIS) this information is used along with patient’s clinical characteristics to triage patients into high and low risk categories. It is well recognised that patients with TIA/MIS are at high risk of having a recurrent ischemic event and this risk is highest in the first 48 hours after the index event. Early identification of those at high risk of recurrence is therefore important for triaging and implementing treatment strategies including the need for hospital admission, urgent investigations and aggressive treatments. In this review we discuss the role of modern vascular and parenchymal neuroimaging in predicting clinical and radiographic outcomes in patients with ischemic stroke, focusing mainly on the subgroup of patients with transient or minor neurological symptoms at presentation.

Trauma: cervical spine

Cervical spine injuries are relatively rare in the pediatric population; however, the consequences of missing a cervical spine injury are devastating. The routine use of radiography and multidetector CT has not been shown to be cost-effective or demonstrate improved outcomes in these patients. A carefully designed clinical protocol that includes defined parameters for reliably differentiating between patients who need imaging and those who do not is essential in the evaluation of children with cervical spinal trauma. The two largest studies evaluating cost and radiation exposure are the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian cervical spine rule (CCR). In the NEXUS study criteria for imaging included midline tenderness, altered level of alertness, intoxication, focal neurological deficit and distracting painful injury. The NEXUS criteria have been studied and have been proved reliable to separate patients into lowand high-risk groups. Additional criteria have been added by some investigators and include high-risk mechanism of injury, transient neurological symptoms, physical signs of trauma, head or face trauma and an inconsolable child. The low-risk child does not require an imaging work-up and, unlike adults, imaging of the high-risk child should begin with radiographs because of the risk of radiation exposure. The initial evaluation of the pediatric cervical spine is with cervical radiographs. The level of injury is commonly higher (C1-3) in children younger than 8 years because of anatomical differences, which makes the injury more easily detected using radiography. A good lateral screening study is usually sufficient in evaluation of pediatric spine trauma and additional views only increase the radiation dose without increasing sensitivity. Multiple useful lines can be obtained on the lateral cervical radiograph including the anterior cervical line, posterior cervical line, spinolaminar line, Wackenheim clivus line and the C2 line. The C2 line is drawn along the posterior C2 body and should intersect the upper corner of C3 and is useful for evaluating subluxation/dislocation. The clivus line is drawn along the clivus and should pass though the posterior one-third of the odontoid. The spinolaminar line is most useful in evaluating for pseudosubluxation at C2-3 level. A multitude of measurements are also available, which include the basiondens interval (less than 12 mm), Power ratio (less than or equal to 1), and the atlanto-dental distance (less than 5 mm). Flexion and extension radiographs have little use in the acute evaluation of pediatric cervical trauma due to patient cooperation, pain and technical limitations. Multidetector CT (MCDT) is useful in evaluating cervical injury in children, but at a significant radiation cost. This modality should be used if cervical radiographs are unclear or suggest injury or if there is a strong clinical concern. Sagittal and coronal reconstructions are necessary for a complete examination. To reduce radiation dose, limited evaluation of the area of concern might be appropriate and if no fractures are identified imaging of the entire cervical spine might not be warranted. It is important to realize that the measurements used on radiographs are not transferable to the MDCT images. In children, the atlanto-dental distance should be less than Disclaimer Dr. Booth has no financial interests, investigational or offlabel uses to disclose.

Accidental Intrathecal Injection of Aminophylline in Spinal Anesthesia

Accidental Intrathecal Injection of Aminophylline in Spinal Anesthesia

Chloroprocaine for spinal anesthesia: a retrospective analysis

Recent volunteer and clinical studies of chloroprocaine (CP) have evaluated its use for outpatient spinal anesthesia. This retrospective review describes the discharge characteristics and reported side effects of spinal CP in a large number of patients undergoing outpatient procedures. All patients who received spinal anesthesia for ambulatory procedures over a 20-month period were accessed using computer-generated reports. Charts from 601 anesthetics were analyzed for spinal drug used, block characteristics, side effects and discharge data. CP was the most frequently used spinal anesthetic (84% of cases, n=503) for outpatient procedures. CP (median dose 40 mg, range 20-60 mg) times from injection to ambulation and discharge were 107±24 and 171±45 min, respectively. Lidocaine (median dose 60 mg, range 30-100 mg, n=84) times from injection to ambulation and discharge were 155±40 and 224±57 min, respectively (P<0.05). The incidence of urinary retention, the most common side effect, was similar in both groups. There were no reports of transient neurologic symptoms. For ambulatory patients at our institution, the time to achievement of discharge criteria was significantly reduced with CP 40 vs. lidocaine 60 mg. There have been no reports of perioperative neurologic injury with the introduction of CP as a spinal anesthetic at our institution.