Therapeutic potential of enzymes, neurosteroids, and synthetic steroids in neurodegenerative disorders: A critical review

Neurodegenerative disorders present a significant challenge to healthcare systems, mainly due to the limited availability of effective treatment options to halt or reverse disease progression. Endogenous steroids synthesized in the central nervous system, such as pregnenolone (PREG), dehydroepiandrosterone (DHEA), progesterone (PROG), and allopregnanolone (ALLO), have been identified as potential therapeutic agents for neurodegenerative diseases. Neurosteroids such as ALLO, DHEA, and PROG, as well as their synthetic analogs like Ganaxolene, Fluasterone, and Olexoxime, offer promising effects for conditions such as Alzheimer's disease (AD) and depression. Moreover, Brexanolone and Ganaxolone are synthetic steroids approved for the treatment of postpartum depression and epilepsy, respectively. Neurosteroids such as ALLO are crucial in modulating GABAergic neurotransmission and reducing neuroinflammation. These compounds enhance the activity of GABA-A receptors, leading to increased inhibitory signaling in the brain, which can help regulate mood, cognition, and neuroprotection. Small clinical trials and observational studies indicate that ALLO may have cognitive benefits, but no large-scale, definitive meta-analysis confirms a 20 % improvement in AD patients. Mitochondrial dysfunction plays a vital role in the pathogenesis of numerous neurological diseases due to the high-energy demand and sensitivity of neurons to oxidative stress. Reduced mitochondrial function leads to amyloid-beta plaques and tau tangles accumulation in AD. In Parkinson's disease (PD), mitochondrial dysfunction resulting from the PINK1 or Parkin genes leads to energy deficiencies and the accumulation of toxic byproducts. Mutations in genes such as SOD1, C9orf72, and TDP-43 have been associated with mitochondrial dysfunction in amyotrophic lateral sclerosis (ALS). Moreover, studies on these neurodegenerative diseases suggest that inflammation is not merely a consequence of neurodegeneration but is also an essential factor in this process. Many neurological disorders involve multifaceted interactions between genetics, the environment, and immune responses, making it difficult to pinpoint their exact causes. Future research aims to overcome these hurdles through genetic advances, regenerative medicine, and personalized therapies. Cutting-edge technologies such as artificial intelligence and high-throughput screening are expected to accelerate drug discovery and improve diagnostic accuracy. Increasing collaboration between interdisciplinary fields such as bioinformatics, neuroscience, and immunology will lead to innovative treatment strategies. This comprehensive review discusses the therapeutic effects of enzymes, neurosteroids, and synthetic steroids in different neurodegenerative diseases, particularly AD, PD, ALS, and MS. Potential challenges in the therapeutic use of neurosteroids, such as the limited bioavailability and off-target effects of synthetic steroids, are also discussed, and an up-to-date and comprehensive review of the impact of these steroids on neurodegenerative disorders is presented.

Ultrasonographic Optic Nerve Sheath Diameter Technical Pitfalls and Imaging Artifacts

Ultrasonographic optic nerve sheath diameter (ONSD) is a non-invasive intracranial pressure (ICP) surrogate. This article discusses the effect of ultrasound settings and imaging artifacts on ONSD assessment. Ultrasound settings that may affect ONSD assessment include gain, dynamic range, frequency, harmonic imaging, and focal zones. Artifacts can be related to imaged structures (acoustic shadowing, enhancement, comet tail, and speckle artifacts) or to beam properties (partial volume and refraction artifacts). In addition, optic nerve sheath (ONS) properties such as echogenicity changes based on ICP or ONS kinking are discussed.

High risk and low incidence diseases: Aneurysmal subarachnoid hemorrhage

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (aSAH) is a serious condition that carries a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of aSAH, including presentation, diagnosis, and management in the emergency department based on current evidence.

DISCUSSION

aSAH is a type of hemorrhagic stroke, most commonly from rupture of a saccular aneurysm, which results in leakage of blood into the subarachnoid space. It presents acutely and has many mimics, making the diagnosis difficult. Patients who present with either sentinel or acute presentation of a headache that is described as sudden or severe, has associated neck stiffness, cranial nerve deficits, syncope, seizure, and/or coma should raise suspicion for the diagnosis. Non-contrast head computed tomography is the imaging modality of choice for evaluation and diagnosis of the disease in patients who present acutely. Further diagnostic testing with lumbar puncture or advanced neuroimaging may be required in patients who present >6 h after symptom onset. Patients with aSAH require critical, multidisciplinary care, with particular attention to management of airway, breathing, and circulation; expeditious referral for neurosurgical intervention; coagulopathy reversal; and prophylaxis against downstream complications.

CONCLUSION

An understanding of aSAH can assist emergency clinicians in diagnosing and managing this disease.

Predicting outcomes in patients with sepsis-associated encephalopathy using prefrontal functional connectivity analysis

We investigated the relationship between prefrontal functional connectivity of oxyhemoglobin and outcomes in sepsis-associated encephalopathy (SAE). Additionally, we developed a prognostic method for patients with SAE. A total of 40 consecutive patients with SAE were prospectively included. Cerebral oxyhemoglobin data were obtained using functional near-infrared spectroscopy. Functional connectivity such as density was evaluated as the strength of the temporal correlation between channels based on Pearson's correlation coefficient of oxyhemoglobin. We obtained clinical information and evaluated severity scores using Acute Physiology and Chronic Health Evaluation (APACHE) III. Outcomes were evaluated using the modified Rankin Scale (mRS) at discharge. Patients were categorized into two groups: good outcome (mRS 0-3), and poor outcome (mRS 4-6). Among the patients with SAE, 17 (42.5%) had good outcomes. Regarding connectivity analysis, density values were significantly higher in good outcome groups at all threshold values. The developed predictive method of good outcomes using the density value at a threshold of 0.6 and the APACHE III score showed very good predictive power (area under the curve 0.951 [95% confidence interval 0.893-1.00]). This method had better discrimination powers for predicting outcome than density had at 0.6 (0.716 [0.557-0.876]; P = 0.04) or the APACHE III score had alone (0.857 [0.735-0.979]; P = 0.09). A higher functional connectivity value of oxyhemoglobin in the prefrontal connectivity analysis was associated with good outcomes in SAE. Functional connectivity analysis of the prefrontal cortex and sepsis severity may help predict the prognosis in SAE patients.

Estimating measured creatinine clearance for critically ill trauma patients with presumed normal kidney function

PURPOSE

The intent of this study was to evaluate the predictive performance of two common methods for estimating kidney function in critically ill trauma patients with presumed normal kidney function.

METHODS

A retrospective analysis of 2 common methods for estimating kidney function, the Cockcroft-Gault (CG) and Chronic Kidney Disease Epidemiology Collaboration (2021 CKD-EPI) equations, was undertaken for adult trauma patients. Patients with a 24-hour urine collection for determination of measured creatinine clearance (mCrCl) within 4 to 14 days after admission were included in the study. Patients with a serum creatinine concentration of >1.5 mg/dL or who required dialysis were excluded.

RESULTS

The 200 patients included in the study had a median (IQR) mCrCl of 184 (141-233) mL/min; both the CG and CKD-EPI equations were biased towards underpredicting mCrCl, with median (IQR) values of 135 (100-177) mL/min and 135 (113-155) mL/min, respectively (P < 0.001). One hundred twenty-two patients had augmented renal clearance (ARC), defined as an mCrCl of >129 mL/min/1.73m2, and those patients had a median (IQR) mCrCl of 216 (188-265) mL/min; both the CG and CKD-EPI equations were biased towards underpredicting mCrCl in patients with ARC: the median (IQR) estimates were 160 (126-197) mL/min and 147 (129-164) mL/min, respectively (P < 0.001). For those without ARC (n = 78), the median (IQR) mCrCl was 125 (98-153) mL/min; both the CG and CKD-EPI equations underpredicted mCrCl, with median estimates of 98 (76-116) mL/min and 112 (92-132) mL/min, respectively (P < 0.001). The CKD-EPI equation outperformed the CG method for all markers of precision in patients without ARC (P < 0.003).

CONCLUSION

Common predictive equations for assessing kidney function in critically ill patients with traumatic injuries underpredicted mCrCl, especially in those with ARC.

Screening of toxic-metabolic encephalopathy with and without epileptic seizure with density spectral array

OBJECTIVE

Although toxic metabolic encephalopathy (TME) is clinically common, distinguishing between TME with/without epileptic findings remains challenging. We examined the efficacy of density spectral array (DSA), a form of power-spectrum electroencephalography (EEG) screening tool, for clinicians not specializing in EEG interpretation to make this distinction.

METHODS

Among 346 patients with suspected TME who underwent EEG for acute impaired consciousness (2012-2023), 149 were ultimately diagnosed with TME (mean age 68.9 ± 13.3 years) were enrolled. Using EEG data, we operationally classified DSAs based on frequency changes, as follows: 1) flame or cyclic (presence of temporal frequency change), 2) band (presence of continuous alpha-range activity), 3) gradation (alpha to delta-range activity), and 4) other patterns. The inter-rater agreement rate for DSA pattern assignment was evaluated in a double-blind manner to confirm the reasonableness of the classification. Additionally, we evaluated the sensitivity and specificity of each DSA pattern at determining the ultimate diagnostic outcomes (TME alone or TME with epileptic findings).

RESULTS

TME alone and TME with epileptic findings were 136 and 13, respectively. The inter-rater agreement for DSA classification was high among clinicians (κ = 0.72-0.92). The flame or cyclic pattern exhibited high specificity (97.1 %), but low sensitivity (23.1 %) for the diagnosis of TME with epileptic findings. Conversely, the band and gradation patterns showed a high specificity (76.9-84.6 %) for the diagnosis of TME alone.

CONCLUSIONS

Overall, our DSA classification demonstrated a high inter-rater agreement rate, indicating utility as a simple yet specific tool for distinguishing TME with and without epileptic findings.

Revisiting the role of steroidal therapeutics in the 21st century: an update on FDA approved steroidal drugs (2000-2024)

Steroids are biologically active polycyclic compounds that have garnered significant scientific attention due to their distinct physiochemical properties and diverse medical applications. Since their invention more than 90 years ago, steroids have remained the most important and necessary class of regulatory molecules in the evolution process of living creatures and have fascinated scientists due to their broad-spectrum biological activities. Over time, scientific innovations and expanded understanding of mechanisms related to diversified biological activities of steroids have made them cheaper, efficient and more specific therapeutic agents which could be effective in the prevention and cure of numerous diseases like cancer, inflammation, asthma, microbial infection, and many more. However, steroidal drugs remain a double-edged sword having significant therapeutic benefits but with incidence of several adverse effects if used for a longer duration and/or with incorrect dose. Nevertheless, novel treatment approaches such as nanoparticles or liposomal drug delivery, real-time monitoring and the use of artificial intelligence in steroidal therapy outweigh their risk factors and provide an effective and safe treatment with minimum adverse effects. Furthermore, the repurposing of steroids in different diseases, e.g. successful use of dexamethasone or hydrocortisone during COVID-19 pandemic has renewed the interest in steroidal therapeutics. The present review provides an update on FDA approved steroidal drugs during the years 2000-2024, the status of their clinical studies, the challenges offered by steroidal therapy and the future perspectives to counterbalance all these challenges. Moreover, this review also delivers useful data on the repurposing of steroidal drugs against various diseases along with the novel techniques used for improved steroid delivery.

Identification of Risk Factors Influencing Hemorrhage Volume in Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Study

OBJECTIVE

This multicenter retrospective study aimed to identify significant risk factors influencing hemorrhage volume in patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

A total of 891 patients diagnosed with SAH were included from multiple medical centers. Data encompassing demographic characteristics, medical history, clinical parameters at admission, and radiographic findings were collected and analyzed. Univariate and multivariate logistic regression analyses were conducted to investigate associations between various risk factors and hemorrhage volume.

RESULTS

This study identifies several factors significantly associated with increased hemorrhage volume in patients with subarachnoid hemorrhage (SAH). Multivariate analysis revealed that diabetes (P = 0.022), hypertension (P = 0.047), and saccular aneurysm morphology (P = 0.008) were independent risk factors for high hemorrhage volume. Additionally, larger aneurysm size (maximum diameter: P = 0.007, neck diameter: P = 0.021) and higher systolic blood pressure after onset (P = 0.002) were also significant predictors of increased hemorrhage volume. Factors such as age (P = 0.05) and time interval to the first CT scan (P = 0.022) were found to be associated with hemorrhage volume in univariate analysis but did not maintain independent significance in multivariate regression.

CONCLUSION

This study highlights key risk factors, including diabetes, hypertension, and saccular aneurysm morphology, which independently contribute to higher hemorrhage volume in SAH patients. Management strategies focusing on early detection and control of these factors may improve clinical outcomes by reducing the risk of hemorrhagic complications. While other factors such as age and time interval to the first CT scan were associated with hemorrhage volume, they did not demonstrate independent causality in the multivariate analysis, suggesting that their role in hemorrhage volume may be secondary or context-dependent.

Diagnosis of Carotid Fibromuscular Dysplasia Using Transoral Ultrasound in the Intensive Care Unit

Fibromuscular dysplasia (FMD) is a rare, non-atherosclerotic vascular disease affecting medium to large arteries, especially the renal and internal carotid arteries (ICAs). The string-of-beads appearance, indicative of alternating areas of stenosis and dilatation, is a key imaging feature typically observed in the distal ICAs. Diagnosing FMD in critically ill patients poses challenges due to the risks associated with traditional imaging methods such as computed tomography angiography (CTA), magnetic resonance angiography, and digital subtraction angiography. We report a case of a 74-year-old woman diagnosed with stroke who required mechanical ventilation in the intensive care unit. Initial Doppler ultrasound revealed a fibrolipid plaque at the left internal carotid artery but could not assess the distal ICAs. Using a transoral approach with an endocavitary transducer, we visualized the distal ICAs, revealing the classic string-of-beads pattern and elevated peak systolic velocities indicative of stenosis. CTA confirmed these findings. The transoral ultrasound approach offers a non-invasive, bedside alternative for assessing the distal portions of the ICAs, making it particularly beneficial in critically ill patients. This case underscores the potential of this technique for timely diagnosis of FMD, warranting further research into its broader applicability in routine evaluations of suspected cases.

Cefepime-induced neurotoxicity

We present a case of severe cefepime-induced neurotoxicity following acute kidney injury in a patient with a fracture-related infection. Despite stopping cefepime, the patient required intubation, ventilation, multiple antiepileptic drugs for seizure control, and haemodialysis.

Contribution

Cefepime-induced neurotoxicity is a reversible cause of encephalopathy. Early recognition and cefepime withdrawal are crucial. As cefepime use in South Africa increases due to antimicrobial resistance, healthcare workers must be aware of this under-recognised, under-reported serious adverse drug reaction.

Delayed diagnosis of Terson syndrome at a neurorehabilitation unit

Terson syndrome (TS) is often overlooked in acute neurological settings, delaying diagnosis and negatively impacting neurorehabilitation. In cases of severe TS, management with vitrectomy can lead to immediate visual recovery, highlighting the importance of timely recognition. This case report presents a case of TS, diagnosed on arrival at a highly specialised neurorehabilitation centre. A male patient in his late 40s was admitted after a left-sided basal ganglia haemorrhage. Following surgical intervention for elevated intracranial pressure, he was transferred to a neurorehabilitation unit, presenting with global aphasia, hemiparesis and bilateral visual unresponsiveness. Fundoscopic examination confirmed dense bilateral vitreous haemorrhages, diagnosing TS. Right-sided vitrectomy resulted in immediate visual improvement, facilitating rehabilitation. Left-sided vitrectomy followed 6 months later. Early assessment of TS during the initial stages of brain injury with elevated intracranial pressure is crucial. Prompt diagnosis may identify candidates for surgical intervention, facilitating faster visual recovery and enhancing overall rehabilitation outcomes.

Postoperative fever following hemispherotomy managed with baclofen: unnoticed treatment

BACKGROUND

There are different types of fever after hemispherotomy; to our knowledge, this is the first time in literature in which baclofen was used to control central fever following hemispherotomy.

CASE PRESENTATION

A 12-year-old female patient who has a history of neonatal hemorrhagic stroke presented with uncontrolled seizures despite receiving three antiepileptic drugs. MRI brain showed marked volume reduction in the left cerebral hemisphere. She underwent a left modified hemispherotomy. Two weeks after surgery, she developed a fever with evidence of infection for which she underwent surgical debridement, the fever subsided gradually and she was discharged after 2 weeks. Then 1 week later, she presented again with a fever and the T-max was 39 °C. After the exclusion of infection and aseptic meningitis, there was a possibility of central fever for which we started baclofen at 5 mg once per day and gradually increased the dose till she reached 20 mg per day at which the fever vanished. The patient remained seizure-free and afebrile for 10 months after surgery.

CONCLUSIONS

Postoperative fever is very common after hemispherectomy or functional hemispherotomy, and the non-infectious etiology is the most encountered. Central fever is a diagnosis of exclusion and its diagnosis leads to avoiding the misuse of antibiotics. We found baclofen safely and successively controlled central fever after hemispherotomy.

BRAIN-SIM: Leveraging Simulation for Neurocritical Care Education with an Innovative Multidisciplinary Approach

Background and ObjectivesEarly recognition and response are paramount in the treatment of neurologic emergencies. Due to its complexity, neurocritical care continues to provoke unease for practitioners and trainees. Simulation provides a realistic opportunity for learners to detect an acutely deteriorating neurologic patient and make rapid-fire treatment decisions. A multidisciplinary simulation-based learning environment may improve trainee confidence when caring for the neurocritical care patient population.MethodsNine simulation lab sessions were performed with a multidisciplinary team including medical students, residents, critical care medicine fellows, advanced practice providers (APP), critical care pharmacy residents, and neuroscience unit nurses. High fidelity manikins capable of reproducing acute neurologic and physiologic emergencies were used. After the simulation, participants completed a survey utilizing Likert scale responses regarding simulation logistics, faculty competence, and pre- and post-simulation confidence levels managing specific acute neurologic emergencies and performing neurocritical care procedural skills.ResultsNine simulation lab sessions were conducted, and thirty-eight surveys were completed. Mean learner confidence levels in managing patients improved from pre- to post-simulation in patients with coma [3.18 ± 0.51 versus 4.32 ± 0.25 (P < .001)], status epilepticus [3.23 ± 0.55 versus 4.36 ± 0.29 (P < .001)], acute ischemic stroke [3.75 ± 0.59 versus 4.63 ± 0.43 (P < .001)], intracerebral hemorrhage [3.25 ± 0.74 versus 4.63 ± 0.43 (P < .001)], intracranial hypertension [3.25 ± 0.74 versus 4.63 ± 0.43 (P < .001)], respiratory failure [3.5 ± 0.77 versus 4.63 ± 0.43 (P = .0016)], and procedures such as central lines [2.2 ± 0.56 versus 3.8 ± 0.56 (P = .003)], intubations [2.25 ± 0.39 versus 3.63 ± 0.62 (P < .001)], and bronchoscopies [2 ± 0 versus 3.2 ± 0.56 (P = .004). Consistently, learners strongly agreed that faculty were knowledgeable, well-informed, and thorough. Learners commented that the simulation experiences were realistic and allowed them to identify areas for improvement.DiscussionSimulation training can be an effective method to improve neurocritical care education by increasing clinician confidence in managing neurologic emergencies and procedures while providing opportunities for multidisciplinary collaboration. Further evaluation of the effectiveness of simulation education in this patient care setting is warranted.

Multidimensional analysis of selected bioelements in rat's brain subjected to stroke procedure and treatment with H2S donor AP-39

BACKGROUND

A stroke is characterized by a sudden disruption in blood flow to the brain. According to WHO statistics, stroke is the second most common cause of death. Its pathophysiology involves complex mechanisms: oxidative stress, inflammation, cytotoxicity and neuronal cell death. Middle cerebral artery occlusion (MCAO) in rats is commonly used to study the pathophysiology of stroke, as well as the efficacy of therapeutic strategies e.g. application of H2S donors.

OBJECTIVES

The aim of this study was to determine the concentrations of minerals (Mg, Na, K), and trace elements (Fe, Cu, and Zn) in rats brain undergoing stroke procedure in the dorsal striatum (ischemic core) and prefrontal cortex (penumbra). We also investigate the application of AP-39 on the levels of above-mentioned minerals and trace elements.

METHODS

Using the MCAO rat model, the impact of stroke and treatment with 100 nmol/kg b.m. i.v. of AP-39 was examined on minerals and trace elements levels, determined by F-AAS and F-AES methods. Results were analyzed using multidimensional statistical analysis (chemometric techniques).

RESULTS

Iron, magnesium, and zinc are the most important bioelements whose concentration changes in both investigated structures were associated with stroke symptoms. The concentrations of zinc and copper showed opposing trend. The application of AP-39 mainly affected the potassium level. In the stroke structure (DS) dosage of AP-39 decreased the potassium level and in non-stroke structure AP-39 increased potassium levels.

CONCLUSION

Stroke and AP-39 treatment significantly altered bioelement concentrations. The bioelements most susceptible to changes under MCAO procedures were zinc, iron and magnesium.

Brain injury plasma biomarkers in patients on veno-arterial extracorporeal membrane oxygenation: A pilot prospective observational study

IntroductionEarly diagnosis of acute brain injury (ABI) is critical for patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) to guide anticoagulation strategy; however, neurological assessment in ECMO is often limited by patient sedation.MethodsIn this pilot study of adults from June 2018 to May 2019, plasma samples of glial fibrillary acidic protein (GFAP), neurofilament light chain (NFL), and tubulin associated unit (Tau) were collected daily after V-A ECMO cannulation and measured using a multiplex platform. Primary outcomes were occurrence of ABI, assessed clinically, and neurologic outcome, assessed by modified Rankin Scale (mRS).ResultsOf 20 consented patients (median age = 48.5°years; 55% female), 8 (40%) had ABI and 15 (75%) had unfavorable neurologic outcome at discharge. 10 (50%) patients were centrally cannulated. Median duration on ECMO was 4.5°days (IQR: 2.5-9.5). Peak GFAP, NFL, and Tau levels were higher in patients with ABI vs. without (AUC = 0.77; 0.85; 0.57, respectively) and in patients with unfavorable vs. favorable neurologic outcomes (AUC = 0.64; 0.59; 0.73, respectively). GFAP elevated first, NFL elevated to the highest degree, and Tau showed limited change regardless of ABI.ConclusionFurther studies are warranted to determine how plasma biomarkers may facilitate early detection of ABIs in V-A ECMO to assist timely clinical decision-making.

Which Intravenous Isotonic Fluid Offers Better Outcomes for Patients with a Brain Injury?

Administering intravenous fluids is a common therapy for critically ill patients. Isotonic crystalloid solutions, such as saline or balanced solutions, are frequently used for intravenous fluid therapy. The choice between saline or a balanced crystalloid has been a significant question in critical care medicine. Recent large randomized controlled trials (RCTs) have investigated whether balanced crystalloids yield better outcomes in general or specific critical care populations, and many of them have confirmed this hypothesis. Although the broad eligibility criteria of these RCTs suggest applicability to neurocritical care patients, it is important to discuss whether using balanced crystalloids, as opposed to saline, would benefit patients who primarily have neurological disorders or diseases. This review considers the relevance of this question, weighs the pros and cons of the two fluid types, examines available data, and anticipates results from ongoing RCTs to guide clinicians in selecting the optimal fluid for patients with brain injury.

Steroid-Induced Mental Disorders in Oncology Patients: A 10-Year Retrospective Case Series Review

OBJECTIVE

Patients with cancer are commonly prescribed corticosteroids for a variety of indications. Corticosteroids have long been known to affect mental state. Neuropsychiatric effects range from insomnia, cognitive impairment, and mood symptoms to psychosis and mania. In this study, we aimed to investigate the demographics, steroid exposure, referring indications, symptom profiles, and subsequent treatments of steroid-induced mental disorders in oncology patients.

METHODS

We conducted a retrospective chart review of patients diagnosed with a steroid-induced mental disorder, as assessed by the psycho-oncology team in Cork University Hospital from 2626 referrals to the service between January 2010 to December 2019.

RESULTS

In total, 297 patients had a diagnosis of steroid-induced mental disorder (11% of referrals). 60.6% were female and mean age ± standard deviation (SD) was 57.5 ± 12.9 years. Breast cancer was the most frequent malignancy among females. Haematological cancer was the most frequent among males and the second most frequent among females. The most commonly prescribed steroid was dexamethasone, followed by prednisolone. The median (interquartile range [IQR]) cumulative weekly prednisolone equivalent dose was 186 mg (125-350 mg), with a median (IQR) duration of steroid exposure before symptom onset of 14 (6-47) days. The most frequently recorded symptoms following psychiatric assessment included insomnia, anxiety, and irritability. Psychotropics were commenced in n = 174 (74%) patients, with antipsychotics prescribed to 62.1%. A watchful wait approach was adopted for 25.5% of the patients. 90.2% (n = 185/205) of the patients experienced either complete or partial resolution of the symptoms at their first clinical review.

CONCLUSIONS

Steroid-induced mental disorders can cause significant comorbidity in patients receiving cancer treatment. The most common symptoms recorded during assessment included insomnia, anxiety, and irritability.

Predictors of poor outcomes in patients with traumatic brain injury at the University Teaching Hospital of Bamenda, Cameroon

OBJECTIVE

This study aimed to determine the various predictors associated to poor outcomes in patients with traumatic brain injury at the University Teaching Hospital of Bamenda, Cameroon.

METHODS

This descriptive and observational study was conducted at the University Teaching Hospital of Bamenda, Cameroon from February 1st 2023 to May 31st 2023. We included all patients managed for TBI in the named hospital within the study period who gave their consent. A prospective inclusion of data was done using a pre-established technical form aimed at collecting sociodemographic information, mechanism of TBI, clinical/paraclinical parameters and Glasgow Outcome Score (GOS) at one month follow-up. Patients with GOS 1, 2, 3 and 4 were considered as having a poor outcome and good outcome for GOS 5. Data collected were entered and analysed using the SPSS statistical software version 25.0.

RESULTS

We found 93 patients who were eligible as per selection criteria. Mean age at presentation was 34.8 ± 15.0 years and there was a male preponderance (87.1 %). Road traffic accident (72 %) was the most common cause of injury followed by assault (14 %) and falls (9.9 %). The overall mortality was 16.1 % and 76.3 % had a good recovery at one month. Poor outcome (GOS<4 at one month) on univariate analysis was associated with delay to treatment > 1 day (p = 0.007, OR = 4.603), GCS less than or equal to 8 (p = 0.000, OR = 3.948), pupillary abnormalities (p = 0.000, OR = 21.630), secondary LOC (p = 0.026, OR = 8.538), intracerebral hematoma (p = 0.036, OR = 3.600), use of diuretics (p = 0.000, OR = 12.143), oxygen saturation less than 90 % (p = 0.026, OR = 5.538) and use of oxygen (p = 0.001, OR = 9.940) in patients with TBI. However, on multivariate analysis, only the GCS (p = 0.044, OR = 12.152) and delay to treatment (p = 0.024, OR = 18.349) retained statistical significance as independent predictors of poor outcomes.

CONCLUSION

Our study suggests that numerous clinical/paraclinical factors such as GCS and patient-related factors like delay in seeking medical care negatively impact outcomes in TBI. This stress the need to carry out adequate clinical evaluation and good therapeutic care by physicians as well as population sensitization in order to reduce the mortality and morbidity related to TBI. Further prospective studies on larger sample size and a longer study period on outcome evaluation are warranted to provide more statistical power to our observations.

Additional Dose of Intravenous Dexamethasone Can Replace Patient-Controlled Analgesia in Pain Control after Total Knee Arthroplasty while Reducing Opioid Complications

The purpose of this study was to evaluate whether intravenous (IV) dexamethasone, within the current multimodal pain management protocol, (1) could maintain postoperative pain at a comparable level without IV patient-controlled analgesia (PCA), (2) could reduce opioids-related side effects, and (3) whether an additional dose of dexamethasone on postoperative day (POD) 2 would offer further pain-relieving effect without increasing the risk of complications. A total of 178 patients (182 knees) who underwent total knee arthroplasty for osteoarthritis were included in the study. The patients were divided into Dexa 2 & PCA and Dexa 3 & NoPCA groups. From operative day to POD 5, pain visual analogue score (VAS), rescue opioids consumption, episodes of postoperative nausea and vomiting (PONV), antiemetics usage, and side effects of opioids such as postoperative urinary retention (POUR) and constipation were checked. For safety, wound complication and infection were checked. There was no difference in pain VAS between the two groups during all six perioperative days. Rescue opioids consumption was lower in Dexa 2 & PCA group. Total dosage of used opioids for six perioperative days was lower in Dexa 3 & NoPCA group. Dexa 3 & NoPCA group had less PONV and POUR. There was a marked increase in pain VAS and the use of rescue opioids from POD 1 to POD 2 in the Dexa 2 & PCA. There were no wound problems or infections in either group. Under the current multimodal pain management protocol, comparable level of postoperative pain could be achieved by dexamethasone without the need of IV PCA. By not using IV PCA, overall opioid usage was reduced, which could lead to a lower frequency of PONV and POUR. While there is still room for further research on the duration and frequency of administering dexamethasone, additional administration on POD 2 is believed to provide additional pain management benefits compared with administering only until POD 1.

Prognostic role of quantitative pupillometry in traumatic brain injury: a scoping review

BACKGROUND

Traumatic brain injury (TBI) is a major cause of global mortality and disability, leading to primary and secondary brain injuries that can result in severe neurological, cognitive, and psychological impairments. Accurate and early prognosis of TBI outcomes is critical, particularly in assessing the risk of neurological decline, intracranial pressure (ICP) changes, and mortality.

OBJECTIVE

This systematic review aims to evaluate the prognostic value of quantitative pupillometry, particularly the Neurological Pupil Index (NPi), in predicting long-term outcomes in TBI patients.

METHODS

A systematic review was conducted following PRISMA guidelines, with the protocol registered on PROSPERO (CRD42023489079). Databases including PubMed, Scopus, and Embase were searched. Studies were included based on predefined inclusion criteria, focusing on the prognostic accuracy of automated pupillometry in TBI patients. Risk of bias was assessed using the Joanna Briggs Institute (JBI) tool, and evidence quality was evaluated using the Best-Evidence Synthesis approach.

RESULTS

Thirteen studies met the inclusion criteria, with sample sizes ranging from 36 to 2258 participants. The studies demonstrated a consistent association between lower NPi values and increased mortality, poorer functional outcomes, elevated ICP, and the need for emergency interventions. Despite variability in study design and sample sizes, strong evidence supported the use of NPi as a reliable prognostic tool in TBI management.

CONCLUSION

Automated infrared pupillometry, particularly through NPi measurement, offers important prognostic value in TBI patients. Incorporating NPi into routine clinical practice could improve the accuracy of prognosis and enhance patient management. Future research should focus on standardizing measurement protocols and validating these findings in larger, more diverse cohorts.

Clinical characteristics and functional outcomes of pediatric Guillain-Barré syndrome admitted to the Neuro-intensive care unit: a decade-long retrospective observational study

BACKGROUND

Guillain-Barré Syndrome (GBS) remains a significant contributor to acute flaccid paralysis in pediatric patients worldwide. Despite its impact, studies focusing on pediatric GBS requiring intensive care unit (ICU) management are limited. This study aimed to address this gap by exploring the clinical and outcome characteristics of pediatric GBS necessitating ICU care.

METHODS

This retrospective observational study, spanning a decade, analyzed the records of 75 pediatric GBS patients admitted to the Neuro-ICU of a tertiary care center in South India. Data included demographics, prodromal symptoms, clinical features, investigations, treatment modalities, and outcomes.

RESULTS

The majority (55/75) of patients were male, with a median age of 12 years. The highest incidence of GBS requiring ICU admission was in the monsoon season. Prodromal symptoms were observed in 56%. Most patients (93.33%) presented with typical GBS symptoms, and 40% had respiratory distress on ICU admission. Acute motor axonal neuropathy (AMAN) was the most common subtype. Approximately 80% required mechanical ventilation, with a median duration of 22.5 days. No in-hospital mortality was recorded. At discharge, most patients had a GBS disability score of 4, improving to 2 at a median follow -up of 228 days.

CONCLUSIONS

Pediatric GBS patients requiring ICU care exhibit distinctive characteristics, including a higher prevalence of AMAN subtype, seasonal clustering, and favorable outcomes with intensive treatment. The absence of in-hospital mortality underscores the effectiveness of prompt ICU admission and dedicated Neuro-intensive care.

High-Grade Subarachnoid Hemorrhage - Beyond Guidelines

Subarachnnoid hemorrhage (SAH) present in a spectrum of clinical severity, from alert with a headache to comatose. High-grade SAH has higher mortality and risk for severe complications including acute respiratory distress syndrome (ARDS) and delayed cerebral ischemia (DCI). Existing treatment approaches for ARDS in SAH require special consideration because of potential impact on intracranial pressure and cerebral perfusion. DCI is a major cause of SAH morbidity and is often discordant with angiographic vasospasm. Current treatment approaches for DCI and vasospasm require further investigation to determine efficacy and risk/benefit. Nimodipine remains the only therapeutic that is proven to improve SAH outcome.

The Impact of Chronic Magnesium Deficiency on Excitable Tissues-Translational Aspects

Neuromuscular excitability is a vital body function, and Mg2+ is an essential regulatory cation for the function of excitable membranes. Loss of Mg2+ homeostasis disturbs fluxes of other cations across cell membranes, leading to pathophysiological electrogenesis, which can eventually cause vital threat to the patient. Chronic subclinical Mg2+ deficiency is an increasingly prevalent condition in the general population. It is associated with an elevated risk of cardiovascular, respiratory and neurological conditions and an increased mortality. Magnesium favours bronchodilation (by antagonizing Ca2+ channels on airway smooth muscle and inhibiting the release of endogenous bronchoconstrictors). Magnesium exerts antihypertensive effects by reducing peripheral vascular resistance (increasing endothelial NO and PgI2 release and inhibiting Ca2+ influx into vascular smooth muscle). Magnesium deficiency disturbs heart impulse generation and propagation by prolonging cell depolarization (due to Na+/K+ pump and Kir channel dysfunction) and dysregulating cardiac gap junctions, causing arrhythmias, while prolonged diastolic Ca2+ release (through leaky RyRs) disturbs cardiac excitation-contraction coupling, compromising diastolic relaxation and systolic contraction. In the brain, Mg2+ regulates the function of ion channels and neurotransmitters (blocks voltage-gated Ca2+ channel-mediated transmitter release, antagonizes NMDARs, activates GABAARs, suppresses nAChR ion current and modulates gap junction channels) and blocks ACh release at neuromuscular junctions. Magnesium exerts multiple therapeutic neuroactive effects (antiepileptic, antimigraine, analgesic, neuroprotective, antidepressant, anxiolytic, etc.). This review focuses on the effects of Mg2+ on excitable tissues in health and disease. As a natural membrane stabilizer, Mg2+ opposes the development of many conditions of hyperexcitability. Its beneficial recompensation and supplementation help treat hyperexcitability and should therefore be considered wherever needed.

Pulse Pressure and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis

Low pulse pressure (PP) in venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a marker of cardiac dysfunction and has been associated with acute brain injury (ABI) as continuous-flow centrifugal pump may lead to endothelial dysregulation. We retrospectively analyzed adults (≥18 years) receiving "peripheral" VA-ECMO for cardiogenic shock in the Extracorporeal Life Support Organization Registry (January 2018-July 2023). Acute brain injury (our primary outcome) included central nervous system (CNS) ischemia, intracranial hemorrhage, brain death, and seizures. Multivariable logistic regressions were performed to examine whether PP ≤10 mm Hg was associated with ABI. Of 9,807 peripheral VA-ECMO patients (median age = 57.4 years, 67% = male), 8,294 (85%) had PP >10 mm Hg versus 1,513 (15%) had PP ≤10 mm Hg. Patients with PP ≤10 mm Hg experienced ABI more frequently versus PP >10 mm Hg (15% versus 11%, p < 0.001). After adjustment, PP ≤10 mm Hg was independently associated with ABI (adjusted odds ratio [aOR] = 1.25, 95% confidence interval [CI] = 1.06-1.48, p = 0.01). Central nervous system ischemia and brain death were more common in patients with PP ≤10 versus PP >10 mm Hg (8% versus 6%, p = 0.008; 3% versus 1%, p < 0.001). Pulse pressure ≤10 mm Hg was associated with CNS ischemia (aOR = 1.26, 95% CI = 1.02-1.56, p = 0.03) but not intracranial hemorrhage (aOR = 1.14, 95% CI = 0.85-1.54, p = 0.38). Early low PP (≤10 mm Hg) at 24 hours of ECMO support was associated with ABI, particularly CNS ischemia, in peripheral VA-ECMO patients.

The electroencephalogram in the diagnosis and classification of status epilepticus: a practical guide

Status epilepticus is a serious neurological emergency requiring swift recognition and treatment. Presentations with prominent motor features are easily recognised but it can be challenging to diagnose those with subtle or no motor features. Electroencephalogram (EEG) remains indispensable in diagnosing, classifying, monitoring and prognosticating of status epilepticus. There are several separate classification systems for seizures, epilepsy and status epilepticus, incorporating clinical features, causes and EEG correlates. This review focuses on using EEG in status epilepticus and provides a practical approach to diagnosis and classification aligning with the current International League Against Epilepsy and American Clinical Neurophysiology Society definitions.

Hypokalemic paralysis in an adolescent following dexamethasone and B12 injection: A case report and literature review

The widespread use of glucocorticoids in clinical practice may occasionally be complicated by hypokalemic paralysis. Previously, only a few cases of glucocorticoid-induced hypokalemic paralysis in healthy adults had been reported. Intriguingly, cases of B12-induced hypokalemia have previously been reported in patients with pernicious anemia. Recently, we experienced a case of hypokalemic paralysis in an adolescent following intramuscular injections of dexamethasone and vitamin B12. Upon exclusion of other causes, a presumptive diagnosis of glucocorticoid-induced hypokalemic paralysis, with a possible but uncertain contribution from B12 supplementation, was made for the patient. After potassium replacement therapy, the patient fully recovered and was discharged after five days. Although glucocorticoids are known to cause hypokalemia through mechanisms such as enhanced transcellular shift or renal excretion, the potential role of vitamin B12 in worsening this effect remains unclear. It is hypothesized that B12 supplementation under certain conditions could influence electrolyte balance and potentially amplify the hypokalemic effects of glucocorticoids. However, this hypothesis is based on a few cases, and further pathophysiological and clinical studies are needed to clarify whether B12 supplementation exacerbates hypokalemia induced by glucocorticoids or if the observation is coincidental or context-specific. Meanwhile, clinicians should be cautious when prescribing glucocorticoids, particularly in combination with B12 supplements. This includes ensuring that both are administered only when clinically indicated, monitoring vital signs and serum potassium levels in at-risk patients, and considering alternatives when appropriate.

Navigating the blood-brain barrier: enhancing blood culture practices in the neuro-ICU

This study evaluates the implementation of a blood culture (BCx) algorithm in the neurology ICU (NICU) to reduce BCx event (BCE) rates. Results show a reduction in BCE rates, without increasing adverse outcomes. The findings support the feasibility of BCx algorithms for improving diagnostic stewardship in the specialized NICU population.

Permissive strategies in intensive care units (ICUs): actual trends?

Permissive strategies in the intensive care unit (PSICU) intentionally allow certain physiological parameters to deviate from traditionally strict control limits to mitigate the risks associated with overly aggressive interventions. These strategies have emerged in response to evidence that rigid adherence to normal physiological ranges may cause harm to critically ill patients, leading to iatrogenic complications or exacerbation of underlying conditions. This review discusses several permissive strategies, including those related to hypotension, hypercapnia, hypoxemia, and lower urinary output thresholds. The key principles of these strategies require careful balancing and close monitoring to ensure that the benefits outweigh the risks for each patient. This approach emphasizes individualized care, thoughtful decision-making, and flexible application of guidelines. The use of a PSICU may help minimize the side effects of treatment while addressing the primary condition of the patient and allowing for a more holistic view of critically ill patients.

Ultrasonographic evaluation of optic nerve sheath diameter in patients severe traumatic brain injury: a comparison with intraparenchymal pressure monitoring

OBJECTIVE

Increased intracranial pressure (ICP) can worsen the clinical condition of traumatic brain injury (TBI) patients. One non-invasive and easily bedside-performed technique to estimate ICP is ultrasonographic measurement of optic nerve sheath diameter (ONSD). This study aimed to analyze ONSD and correlate it with ICP values obtained by intraparenchymal monitoring to establish the ONSD threshold value for elevated ICP and reference range of ONSD in severe TBI patients.

METHODS

Forty severe TBI patients (Glasgow Coma Scale Score ≤ 8) were included. Ultrasonographic measurement of ONSD was performed and compared with intraparenchymal ICP monitoring to assess their association and determine the ONSD threshold value. Exclusion criteria included individuals under eighteen years old, penetrating TBI, or direct ocular trauma.

RESULTS

Fifty-three ONSD measurements were conducted in all patients. The mean ONSD value in the group with intracranial pressure < 20 mmHg was 5.4 mm ± 1.0, while in the group with intracranial pressure ≥ 20 mmHg, it was 6.4 mm ± 0.7 (p = 0.0026). A positive and statistically significant correlation, albeit weak (r = 0.33), was observed between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring. The statistical analysis of the ROC curve identified the best cut-off as 6.18 mm, with 77.8% sensitivity and 81.8% specificity.

CONCLUSION

Our results reveal a positive, albeit weak, correlation between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring, with an ONSD threshold value of 6.18 mm. Achieving only 77.8% sensitivity and considering the substantial variability between ONSD measurements (standard deviation at 1.0) might limit the reliability of ICP assessment based solely on ONSD measurements.

Automated quantitative pupillometry as a predictor for transtentorial brain herniation in patients with malignant acute ischemic stroke

Brain herniation can be a life-threatening condition, resulting in poor prognosis and higher fatality rates. We examined whether quantitative characteristics of sequential pupillary light reflex (PLR) could serve as biomarkers for identifying brain herniation in fatal acute stroke cases with anterior circulation involvement admitted to neurological intensive care unit (Neuro-ICU). Automatic pupillometer assessed PLR automatically every 4-6 hours, measuring eight specific features: NPi (Neurological pupil index) score, initial resting and constriction pupil size, constriction change, constriction velocity, constriction latency, and dilation velocity. Generalized estimating equations were used to analyze the main effects of assessment time (3-to-0 hours, just before brain herniation, and 27-to-21 hours, considerably before) and clinical groups. The study involved 59 patients (mean age 68.8 ± 1.6 years, 23 females) divided into herniation (n = 10) and non-herniation (n = 49) groups. The herniation group exhibited significantly lower ipsilateral NPi scores at 3-to-0 hours (1.80 ± 0.44, p < 0.0001) compared to 27-to-21 hours (4.26 ± 2.21). Additionally, the herniation group had a larger ipsilateral pupil size at constriction at 3-to-0 hours (4.01 ± 0.40 mm) compared to 27-to-21 hours (2.11 ± 0.17 mm). Specifically, at 3-to-0 hours, the herniation group had lower NPi scores (1.80 ± 0.44 vs. 3.97 ± 0.13, p < 0.0001) and larger pupil size at constriction (4.01 ± 0.04 mm vs. 2.90 ± 0.10 mm, p = 0.007) compared to the non-herniation group. These findings suggest that evaluating PLR characteristics can aid in the early identification of brain herniation, facilitating timely triage and appropriate surgical management.

Airway management and functional outcomes in intubated patients with ischemic stroke

We investigated the functional outcomes in ischemic stroke patients who underwent endotracheal intubation according to airway management (i.e., extubation success, extubation failure, primary tracheostomy) at multiple time points. Patients were classified into three groups: extubation success, extubation failure, and primary tracheostomy. Their functional outcomes were compared at hospital discharge, 3-month, and 1-year. Out of 165 ischemic stroke patients, 84 (50.9%) underwent extubation attempt and 81 (49.1%) underwent primary tracheostomy. Among the patients who underwent extubation, 26 (31.0%) experienced extubation failure. The extubation success group had a higher rate of achieving a favorable functional outcome (modified Rankin Scale 0-4) compared to the extubation failure group at hospital discharge (adjusted odds ratio [aOR] 3.93; 95% CI, 1.33-13.1; p = 0.018) and at 3-month (aOR 5.67; 95% CI 1.79-19.8; p = 0.004), but not at 1-year (aOR 2.99; 95% CI 0.96-9.68; p = 0.061). The primary tracheostomy group had a significantly lower rate of achieving a favorable functional outcome at all time points compared to the extubation failure group. These findings suggest that a condition suitable for an extubation attempt may be a more important 1-year prognostic indicator than extubation failure. Despite its limitations, this study suggests that the clinical condition prompting primary tracheostomy may outweigh extubation failure as a determinant of 1-year prognosis. However, prospective studies are needed to validate it and clarify its clinical implications.

Correlation Between Quantitative Background Suppression on EEG and Serum NSE in Patients With Hypoxic-ischemic Encephalopathy

PURPOSE

We evaluated the correlation between quantitative background activities on electroencephalography (EEG) and serum neuron specific enolase (NSE) in patients with hypoxic-ischemic encephalopathy as well as a diagnostic value of prognostication.

METHODS

This retrospective cohort study enrolled patients with return of spontaneous circulation after cardiac arrest from March 2010 to March 2020. The inclusion criteria were (1) older than the age of 16 years and (2) patients who had both EEG and NSE. The median time for EEG and NSE were 3 days (interquartile range 2-5 days) and 3 days (interquartile range 2-4 days), respectively. The quantification of background activity was conducted with the suppression ratio (SR). We used a machine learning (eXtreme Gradient Boosting algorithm) to evaluate whether the SR could improve the accuracy of prognostication.

RESULTS

We enrolled 151 patients. The receiver operating characteristic analysis revealed a cut-off value of serum NSE and the SR for poor outcome, serum NSE (>31.9 μg/L, area under curve [AUC] = 0.88), and the SR (>21.5%, AUC = 0.75 in the right hemisphere, >34.4%, AUC = 0.76 in the left hemisphere). There was a significant positive correlation between the severity of SR and the level of NSE ( ρ = 0.57, p < 0.0001 for the right hemisphere, ρ = 0.58, p < 0.0001 for the left hemisphere). The SR showed an excellent diagnostic value for predicting poor outcome (93% specificity, 60% sensitivity in the right hemisphere and 93% specificity, 58% sensitivity in the left hemisphere). With machine learning analysis, there was an increment in distinguishing the neurological outcome by adding SR on clinical factors.

CONCLUSIONS

The SR showed a positive correlation with the level of serum NSE. The diagnostic value of the SR for predicting poor outcome was excellent, suggesting that it can be a possible biomarker for neuroprognostication in patients with hypoxic-ischemic encephalopathy.

Effect of perioperative magnesium sulfate on neurological outcome in neurosurgical patients: a randomized double-blind controlled trial

BACKGROUND

Supplemental magnesium sulfate has a potential neuroprotective role in acute brain injury. It is safe, widely available, and inexpensive. This study evaluated the effect of perioperative intravenous administration of magnesium sulfate on brain damage caused by neurosurgery.

METHODS

Prospective randomized double-blind controlled study. Fifty adult patients undergoing supratentorial neurosurgery (25 were assigned to magnesium sulfate group and 26 to the control group). On arrival to the operating room, the intervention group received intravenous magnesium sulfate, 4 g bolus in 100 mL of 0.9% saline solution lasting 20 min followed by 20 g in 1000 mL saline lasting 24 h. The control group received the same volume of saline. Serum S100B-protein levels 2 h after surgery was the primary outcome. Secondary outcomes were neuron-specific enolase, magnetic resonance imaging (MRI) parameters, neuropsychological testing, Glasgow Outcome Scale, and mortality, during hospital stay and at six and 12 months after surgery.

RESULTS

Statistically significant differences in the primary outcome were not found. At six months, MRI showed a mean surgical cavity volume of 10.0 cm3 (95% confidence interval [CI] 4.4-15.6) in the magnesium group vs. 26.9 cm3 (95% CI 13.8-39.9) in controls (P=0.02), gliosis/edema in 55% vs. 90.5% (P=0.014), and contrast enhancement around the cavity in 33.3% vs. 80% (P=0.041), respectively. Patients in the magnesium group showed better scores in some neuropsychological tests. There were no relevant adverse effects in magnesium group.

CONCLUSIONS

Neurosurgical patients treated with supplemental magnesium sulfate showed macroscopic improvement in some MRI parameters related to blood-brain barrier permeability and better performance in some focal cognitive domain.

Combined Use of Intranasal Methylprednisolone and Allopregnanolone: Revisiting Anti-inflammatory and Remyelinating Treatment in a Murine Model of Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is a demyelinating, neuroinflammatory, progressive disease that severely affects human health of young adults. Neuroinflammation (NI) and demyelination, as well as their interactions, are key therapeutic targets to halt or slow disease progression. Potent steroidal anti-inflammatory drugs such as methylprednisolone (MP) and remyelinating neurosteroids such as allopregnanolone (ALLO) could be co-administered intranasally to enhance their efficacy by providing direct access to the central nervous system (CNS).

METHODS

The individual and combined effects of MP and ALLO to control the clinical score of murine experimental autoimmune encephalitis (EAE), to preserve spinal cord tissue integrity, modulate cellular infiltration and gliosis, promote remyelination, and modify the expression of Aryl hydrocarbon receptor (AhR) were evaluated. In silico studies, to deep insight into the mechanisms involved for the treatments, were also conducted.

RESULTS

MP was the only treatment that significantly reduced the EAE severity, infiltration of inflammatory cells and ionized calcium-binding adapter molecule 1 (Iba-1) expression respect to those EAE non-treated mice but with no-significant differences between the three treatments. MP, ALLO and MP+ALLO significantly reduced tissue damage, AhR expression, and promoted remyelination. Overall, these results suggest that MP, with or without the co-administration with ALLO is an effective and safe strategy to reduce the inflammatory status and the progression of EAE. Despite the expectations of the use of ALLO to reduce the inflammation in EAE, its effect in the dose-scheme used herein is limited only to improve myelination, an effect that supports its usefulness in demyelinating diseases. These results indicate the interest in exploring different doses of ALLO to recommend its use.

CONCLUSIONS

ALLO treatment mainly maintain the integrity of the spinal cord tissue and the presence of myelin without affecting NI and the clinical outcome. AhR could be involved in the effect observed in both, MP and ALLO treatments. These results will help in the development of a more efficient therapy for MS patients.

Posterior Basolateral Amygdala is a Critical Amygdaloid Area for Temporal Lobe Epilepsy

The amygdaloid complex consists of multiple nuclei and is a key node in controlling temporal lobe epilepsy (TLE) in both human and animal model studies. However, the specific nucleus in the amygdaloid complex and the neural circuitry governing seizures remain unknown. Here, it is discovered that activation of glutamatergic neurons in the posterior basolateral amygdala (pBLA) induces severe seizures and even mortality. The pBLA glutamatergic neurons project collateral connections to multiple brain regions, including the insular cortex (IC), bed nucleus of the stria terminalis (BNST), and central amygdala (CeA). Stimulation of pBLA-targeted IC neurons triggers seizures, whereas ablation of IC neurons suppresses seizures induced by activating pBLA glutamatergic neurons. GABAergic neurons in the BNST and CeA establish feedback inhibition on pBLA glutamatergic neurons. Deleting GABAergic neurons in the BNST or CeA leads to sporadic seizures, highlighting their role in balancing pBLA activity. Furthermore, pBLA neurons receive glutamatergic inputs from the ventral hippocampal CA1 (vCA1). Ablation of pBLA glutamatergic neurons mitigates both acute and chronic seizures in the intrahippocampal kainic acid-induced mouse model of TLE. Together, these findings identify the pBLA as a pivotal nucleus in the amygdaloid complex for regulating epileptic seizures in TLE.

Utility of CT perfusion in seizures and rhythmic and periodic patterns

OBJECTIVE

CT hyper-perfusion has been reported in non-convulsive status epilepticus (NCSE), while its occurrence and relevance after single seizures or with rhythmic and periodic patterns (RPPs) that lie along the ictal-interictal continuum (IIC), remain unclear. The goal of the study is to assess the role of CT perfusion (CTP) in diagnosing patients with clinical seizures, subclinical seizures, or RPPs that lie along the IIC, to help in the clinical assessment of these entities.

METHODS

We retrospectively reviewed inpatients who underwent a CTP and an EEG within 6 h of each other. CTP and EEGs were blindly reviewed independent of electronic medical records.

RESULTS

Out of 103 patients, 15 patients (15 %) demonstrated hyper-perfusion, 40 patients (39 %) had hypo-perfusion, while 48 patients (47 %) had normal CTP. Patients with focal CTP hyperperfusion were more likely to have clinical seizures, electrographic seizures, and/or lateralized rhythmic periodic patterns (RPPs) compared to those without CTP hyperperfusion. Focal CTP hyper-perfusion had 34 % sensitivity and 96 % specificity for identifying patients with clinical seizures, and a 40 % sensitivity and 92 % specificity for identifying patients with electrographic seizures or lateralized RPP. Although the numbers were small, none of the patients with generalized periodic discharges or generalized rhythmic delta activity had CTP hyper-perfusion.

CONCLUSIONS

Focal CTP hyper-perfusion has low sensitivity but high specificity for identifying patients with seizures and lateralized RPPs, and may be considered in the clinical assessment of patients where the clinical information are unclear or insufficient.

SIGNIFICANCE

The presence of CTP hyper-perfusion should alert the physician to the possibility of an ictal related etiology accounting for the patient's symptoms.

Steroids and Immunomodulatory Therapies for Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is characterized by a dysregulated immune response to infection or injury. This framework has driven long-standing interest in immunomodulatory therapies as treatments for ARDS. In this narrative review, we first define what constitutes a dysregulated immune response in ARDS. In this context, we describe the rationale and available evidence for immunomodulatory therapies studied in randomized controlled trials of ARDS patients to date. Finally, we address factors that have contributed to the failure to develop therapies in the past and highlight current and future developments designed to address them.

The Development of Algorithms for Individual Ranges of Body Temperature and Oxygen Saturation in Healthy and Frail Individuals

BACKGROUND/OBJECTIVES

Individual habitual conditions entail a risk during the interpretation of vital parameters. We developed algorithms for calculating, validating, and interpreting individual normal ranges of body temperature and oxygen saturation.

METHODS

In total, 70 healthy individuals aged 27 to 80 and 52 frail individuals aged 60 to 100 were included. Data on individual conditions comprised age, gender, physical ability, chronic disease, and medication. Ear temperature and oxygen saturation were measured for five mornings before the participants got out of bed and consumed medicine, food, or drink.

RESULTS

The range for body temperature was 34.3 °C to 37.7 °C, with a variation of 0.7 °C ± 0.4 °C. The variation in minimum and maximum temperatures was 2.4 °C vs. 2.7 °C and 2.9 °C vs. 2.3 °C in healthy and frail subjects, respectively. The range for oxygen saturation was 85% to 99% in healthy individuals and 75% to 100% in frail individuals. The variation between minimum and maximum oxygen saturation was 13% vs. 25% and 4% vs. 17% in healthy and frail subjects, respectively.

CONCLUSIONS

To promote the implementation of precision medicine in clinical practice, it is necessary to interpret body temperature and oxygen saturation based on individual habitual conditions. Interpreting deviations from an individual's normal ranges allows healthcare professionals to provide necessary treatment without delay, which can be decisive in preventing further deterioration.

Intracranial pressure trends and clinical outcomes after decompressive hemicraniectomy in malignant middle cerebral artery infarction

BACKGROUND

Malignant middle cerebral artery infarction (MMI) is associated with a high incidence of severe disability and mortality. Decompressive hemicraniectomy has become a recognized treatment that can improve the prognosis for patients if performed within a certain time window. Nevertheless, despite this intervention, a mortality rate of approximately 20-40% persists following the surgery. The trends and clinical implications of intracranial pressure (ICP) in these situations remain unclear. We aimed to investigate whether intracranial pressure (ICP) trends are associated with clinical outcomes in patients undergoing decompressive hemicraniectomy for MMI.

METHODS

This retrospective cohort study included consecutive patients with MMI who underwent decompressive craniectomy and received ICP monitoring after surgery. Using a linear mixed model, we categorized the patients into ICP increase and decrease groups based on the ICP values obtained over 192 h. We then compared the proportion of 3-month favorable outcomes (modified Rankin Scale of 0-4) and mortality rates between these groups.

RESULTS

Of 112 MMI patients who underwent decompressive hemicraniectomy, 66 (58.9%) received invasive ICP monitoring. ICP monitoring was performed for a median of 146.5 h (IQR 72.5-181.8). Among the 66 patients, 37 (56.1%) were in the ICP increase group, and 29 (43.9%) were in the ICP decrease group. During the monitoring period, the initial monitored ICP and peak ICP did not significantly differ between the ICP increase and decrease groups. However, the ICP trend was significantly different between the two groups (P < 0.001). In multivariable logistic regression analyses, the ICP increase group had a significantly lower proportion of 3-month favorable outcomes compared to the ICP decrease group (adjusted OR 0.11; 95% CI, 0.01-0.59; P = 0.019), and significantly higher mortality in the intensive care unit (adjusted OR 6.98; 95% CI, 1.37-54.6; P = 0.031).

CONCLUSIONS

In MMI patients, continuous ICP monitoring could be useful for detecting those with an increasing ICP trend that may be associated with unfavorable clinical outcomes.

Immunoglobulin G4-related spinal pachymeningitis: A case report

BACKGROUND

Immunoglobulin G4-related disease (IgG4-RD) is a complex immune-mediated condition that causes fibrotic inflammation in several organs. A significant clinical feature of IgG4-RD is hypertrophic pachymeningitis, which manifests as inflammation of the dura mater in intracranial or spinal regions. Although IgG4-RD can affect multiple areas, the spine is a relatively rare site compared to the more frequent involvement of intracranial structures.

CASE SUMMARY

A 70-year-old male presented to our hospital with a two-day history of fever, altered mental status, and generalized weakness. The initial brain magnetic resonance imaging (MRI) revealed multiple small infarcts across various cerebral regions. On the second day after admission, a physical examination revealed motor weakness in both lower extremities and diminished sensation in the right lower extremity. Electromyographic evaluation revealed findings consistent with acute motor sensory neuropathy. Despite initial management with intravenous immunoglobulin for presumed Guillain-Barré syndrome, the patient exhibited progressive worsening of motor deficits. On the 45th day of hospitalization, an enhanced MRI of the entire spine, focusing specifically on the thoracic 9 to lumbar 1 vertebral level, raised the suspicion of IgG4-related spinal pachymeningitis. Subsequently, the patient was administered oral prednisolone and participated in a comprehensive rehabilitation program that included gait training and lower extremity strengthening exercises.

CONCLUSION

IgG4-related spinal pachymeningitis, diagnosed on MRI, was treated with corticosteroids and a structured rehabilitation regimen, leading to significant improvement.

Protopanaxadiol derivative: A plant origin of novel selective glucocorticoid receptor modulator with anti-inflammatory effect

Constant efforts have been made to move towards maintaining the positive anti-inflammatory functions of glucocorticoids (GCs) while minimizing side effects. The anti-inflammatory effect of GCs is mainly attributed to the inhibition of major inflammatory pathways such as NF-κB through GR transrepression, while its side effects are mainly mediated by transactivation. Here, we investigated the selective glucocorticoid receptor modulator (SGRM)-like properties of a plant-derived compound. In this study, glucocorticoid receptor (GR)-mediated alleviation of inflammation by SP-8 was investigated by a combination of in vitro, in silico, and in vivo approaches. Molecular docking and cellular thermal shift assay suggested that SP-8 bound stably to the active site of GR via hydrogen bonding and hydrophobic interactions. SP-8 activated GR, induced GR nuclear translocation, and inhibited NF-κB pathway activation. Furthermore, SP-8 did not up-regulate the gene and protein expression of PEPCK and TAT in HepG2 cells, and it did not induce fat deposition like GC and has little effect on bone metabolism. Interestingly, SP-8 upregulated GR protein expression and did not cause GR phosphorylation at Ser211 in RAW264.7 cells. This work proved that SP-8 dissociated characteristics of transrepression and transactivation can be separated. In addition, the in vitro and in vivo anti-inflammatory effects of SP-8 were confirmed in LPS-induced RAW 264.7 cells and in a mouse model of DSS-induced ulcerative colitis, respectively. In conclusion, SP-8 might serve as a potential SGRM and might hold great potential for therapeutic use in inflammatory diseases.

Augmented Renal Clearance: Prevalence, Risk Factors and Underlying Mechanism in Critically Ill Patients with Subarachnoid Hemorrhage

BACKGROUND

Augmented renal clearance (ARC) is an increase in the measured creatinine clearance (CLCR), the cause of which remains poorly understood. ARC may be associated with drug underdosing and appears to be more frequent in patients with brain damage, such as subarachnoid hemorrhage (SaH), although the incidence of ARC remains poorly understood. The aim of this study was to investigate the prevalence of ARC in patients with SaH in a neurointensive care unit (neuro-ICU) and to identify factors associated with ARC.

METHODS

All consecutive patients hospitalized in the neuro-ICU of Bordeaux University Hospital between June 2018 and June 2019 for SaH treatment were retrospectively included. CLCR was measured daily via 24-h urine collection. ARC was defined as a CLCR ≥ 130 mL/min/1.73 m2. The effects of different covariates on the time course of CLCR were investigated using a linear mixed model.

RESULTS

Of the 205 included study participants, 168 developed ARC during their neuro-ICU stay; the estimated ARC prevalence was 82% (95% confidence interval 76-87) with a median of 4 days (range 3-6 days) after hemorrhage; ARC persisted for a median of 5 days (range 2-8 days). Patients with ARC were younger and had a lower BMI and lower mortality rate. In multivariate analysis, younger patients with a higher mean arterial pressure, no history of hypertension, and greater nitrogen loss were more likely to have ARC.

CONCLUSIONS

Augmented renal clearance is very common in critically ill patients with SaH, persists over time, and seems to lack specific risk factors. Daily CLCR measurements could be essential.

Isolated reversible mydriasis was associated with the use of nebulized ipratropium bromide: a case series using quantitative pupilometer in Korea

BACKGROUND

Abnormal pupillary reactivity is a neurological emergency requiring prompt evaluation to identify its underlying causes. Although isolated unilateral mydriasis without accompanying neurological abnormalities is rare, it has occasionally been associated with nebulizer use. We aimed to quantitatively assess pupillary changes using a pupillometer in cases of isolated mydriasis, which has not been described in previous studies.

METHODS

We retrospectively analyzed patients who developed unilateral mydriasis after using an ipratropium bromide nebulizer using a prospectively collected database in the intensive care unit (ICU) between April 2019 and August 2020. An automated pupillometer (NPi-100 or NPi-200) was used for quantitative pupillary assessment. The Neurological Pupil index (NPi) value at the time of unilateral mydriasis was assessed, and the latency before and after the application of the ipratropium bromide nebulizer was measured.

RESULTS

Five patients with isolated mydriasis were identified (mean age, 68 years; male, 60.0%), none of whom had neurological abnormalities other than pupillary light reflex abnormalities. A quantitative pupillometer examination revealed that the affected pupil was larger (5.67 mm vs. 3.20 mm) and had lower NPi values (0.60 vs. 3.40) than the unaffected side. These abnormalities resolved spontaneously without treatment (pupil size, 3.40 mm; NPi, 3.90). The affected pupil had a prolonged latency of 0.38 seconds (vs. 0.28 seconds), which improved to 0.30 seconds with the resolution of the anisocoria.

CONCLUSIONS

In the ICU setting, it is important to keep in mind the ipratropium bromide nebulizer as the benign cause of unilateral mydriasis. Further, an automated pupilometer may be a useful tool for evaluating unilateral mydriasis.

Cancer Therapy-Induced Encephalitis

Encephalitis associated with cancer therapies is a rare but serious complication that can significantly impact patients' quality of life and it requires prompt identification and management. Over the past two decades, immunotherapy-particularly immune checkpoint inhibitors-has become a cornerstone of cancer treatment, with up to half of metastatic cancer patients in economically developed countries now receiving these therapies. The widespread adoption of immunotherapy has led to improved survival rates and long-term remissions, even in patients with advanced metastatic disease. However, as immune modulators, these therapies can trigger a range of immune-related adverse events, including a variety of novel neurological toxicities. Among these, encephalitis is of particular concern due to its potential severity, which can compromise treatment outcomes. This review aims to provide a comprehensive overview of the literature on this condition, highlighting optimal diagnostic strategies and management approaches to mitigate the risk of significant morbidity, while also comparing encephalitis induced by immunotherapy with that caused by traditional chemotherapies and targeted oncologic treatments.

No Benefit of 3% Hypertonic Saline Following Experimental Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a stroke subtype with a high mortality rate (~ 40%). After ICH, the mass effect of the hematoma and edema contribute to raised intracranial pressure (ICP) and poor outcome. Endogenous compensatory mechanisms that blunt ICP elevations include redirection of venous blood and cerebrospinal fluid, along with brain tissue compliance (e.g., decreased cell volume, increased cell density); however, these limited reserves can be exhausted after severe stroke, resulting in decompensated ICP that requires careful clinical management. Management strategies can include administration of hypertonic saline (HTS), an osmotic agent that putatively attenuates edema, and thereby ICP elevations. Evidence regarding the efficacy of HTS treatment following ICH remains limited. In this study, adult male rats were given a collagenase-induced striatal ICH and a bolus of either 3% HTS or 0.9% saline vehicle at 2- and 14-hours post-stroke onset. Neurological deficits, edema, ipsilateral cell volume and density (in areas S1 and CA1), and contralateral CA1 ultrastructural morphology were assessed 24 h post-ICH. Animals had large bleeds (median 108.2 µL), extensive edema (median 83.9% brain water content in ipsilateral striatum), and evident behavioural deficits (median 5.4 neurological deficit scale score). However, HTS did not affect edema (p ≥ 0.4797), behaviour (p = 0.6479), cell volume (p ≥ 0.1079), or cell density (p ≥ 0.0983). Qualitative ultrastructural assessment of contralateral area CA1 suggested that HTS administration was associated with paradoxical cellular swelling in ICH animals. Overall, there was no benefit with administering 3% HTS after ICH.

A Case of Spinal Cord Infarction With Pansensory Deficit: Discussing the Possible Etiology

Spinal cord infarction (SCI) is a rare vascular condition that can lead to the sudden onset of myelopathy, manifesting as paraplegia, bladder and bowel dysfunction, and/or sensory impairments. The primary arteries supplying the spinal cord are the anterior spinal artery (ASA) and the posterior spinal artery (PSA). The ASA mainly provides blood to the anterior two-thirds of the spinal cord, excluding the posterior columns, while the PSA primarily supplies the posterior one-third, which includes the posterior columns. It is relatively uncommon for vascular SCI to result in complete sensory loss, as the area supplied by the ASA is mainly associated with superficial sensation, while the PSA is related to deep sensation. In this report, we describe a case of SCI with pansensory deficits and explore the potential causes of pansensory loss in SCI. The patient was a 51-year-old healthy woman who experienced sudden lower back discomfort, progressing to bilateral lower limb weakness within 30 minutes, accompanied by urinary retention after lifting a heavy object. She was transferred to the hospital with stable vitals except for high blood pressure. A neurological examination revealed significant weakness in her lower limbs, hypesthesia below the Th10 level, bathyanesthesia, and areflexia. Spinal MRI showed hyperintensities at the Th11-Th12 levels, leading to a diagnosis of spinal cord infarction. She was treated with methylprednisolone, heparin, and rehabilitation. Over time, her muscle strength and sensory loss improved, though dysesthesia persisted. After 80 days of treatment and rehabilitation, she was able to walk independently with assistance and was discharged.

The etiological spectrum of miliary brain lesions: A systematic review of published cases and case series

OBJECTIVE

This systematic review aimed to evaluate the published cases with miliary brain lesions and their etiological factors, clinical manifestations, diagnostic procedures, and outcomes.

METHODS

A comprehensive search of PubMed, Scopus, Embase, and Google Scholar was conducted using the specified search strategy. Eligibility criteria included cases with miliary lesions in the brain confirmed through neuroimaging and various diagnostic procedures. The PRISMA guidelines were followed, and the PROSPERO registration number for the protocol is CRD42023445849.

RESULTS

Data from 130 records provided details of 140 patients. Tuberculosis was the primary cause in 93 cases (66.4%), malignancies in 36 cases (25.7%), and other causes accounted for the remaining 11% cases. Tuberculosis patients averaged 35.7 years old, while those with malignancies averaged 55.44 years. Tuberculosis symptoms primarily included fever, headache, and altered sensorium, whereas malignant cases often exhibited progressive encephalopathy, headache, and specific neurological deficits. Distinctive indicators for CNS tuberculosis were choroidal tubercles and paradoxical reactions. Additionally, 63 tuberculosis patients showed miliary lung shadows and 49 had abnormal CSF findings. For the malignancy group, 13 exhibited miliary lung lesions, and 8 had CSF abnormalities. Regarding outcomes, a significant mortality disparity was observed, with 58.3% in the malignancy group, compared to 10.8% in the tuberculosis group and 27.3% in other cases.

CONCLUSION

Miliary brain lesions are a crucial imaging abnormality that necessitates prompt work up. In an immunocompromised state, diagnostic possibilities of miliary brain lesions are more varied and often pose a bigger challenge.

Bilateral Globus Pallidus Lesions and Delayed Hypoxic Encephalopathy Induced by Overuse of Transdermal Fentanyl Patches

We describe a rare case of bilateral globus pallidus lesions (BPL) and delayed hypoxic encephalopathy (DHE) induced by the overuse of transdermal fentanyl patches. The patient was a 54-year-old woman, who had a history of unexplained, intractable anal pain, for which several medications were prescribed, but with very limited effectiveness. Four days prior to admission, she was newly prescribed transdermal fentanyl patches at a dose of 4 mg/day. She developed impaired consciousness and respiratory distress after applying more than 10 fentanyl patches across her body. Brain computed tomography (CT) revealed a lesion in the left globus pallidus. She was treated with naloxone and mechanical ventilation in the intensive care unit and regained consciousness, being discharged from the hospital on day 9. However, she later experienced cognitive and behavioral changes, prompting a return to her previous hospital. Brain magnetic resonance imaging (MRI) revealed BPL with hyperintensities on T2-weighted imaging. After readmission, she again developed impaired consciousness and became fully dependent on care. Although her consciousness gradually improved, she developed higher brain dysfunction, myoclonus, and parkinsonism. A follow-up brain MRI two months after the initial onset showed abnormal signals in the deep white matter bilaterally, along with BPL, with hyperintensities in limited areas on T1-weighted imaging and widespread hyperintensities on T2-weighted imaging. The diagnosis of DHE was based on the extent of bilateral white matter lesions. With rehabilitation treatment, her condition improved to the point where she could manage daily life, though attention and memory impairments persisted. Transdermal fentanyl patches are widely used in clinical practice due to their high efficacy and safety. However, fentanyl overuse has been associated with BPL and DHE, although the exact mechanism remains unclear. This report highlights that even with transdermal administration, overdose can lead to severe neurological side effects.

Imaging Findings Post-Stereotactic Radiosurgery for Vestibular Schwannoma: A Primer for the Radiologist

Noninvasive tumor control of vestibular schwannomas through stereotactic radiosurgery allows high rates of long-term tumor control and has been used primarily for small- and medium-sized vestibular schwannomas. The posttreatment imaging appearance of the tumor, temporal patterns of growth and treatment response, as well as extratumoral complications can often be both subtle or confusing and should be appropriately recognized. Herein, the authors present an imaging-based review of expected changes as well as associated complications related to radiosurgery for vestibular schwannomas.

Longer Periods of Hypothermia Provide Greater Protection Against Focal Ischemia: A Systematic Review of Animal Studies Manipulating Treatment Duration

Decades of animal research show therapeutic hypothermia (TH) to be potently neuroprotective after cerebral ischemic injuries. While there have been some translational successes, clinical efficacy after ischemic stroke is unclear. One potential reason for translational failures could be insufficient optimization of dosing parameters. In this study, we conducted a systematic review of the PubMed database to identify all preclinical controlled studies that compared multiple TH durations following focal ischemia, with treatment beginning at least 1 hour after ischemic onset. Six studies met our inclusion criteria. In these six studies, six of seven experiments demonstrated an increase in cerebroprotection at the longest duration tested. The average effect size (mean Cohen's d ± 95% confidence interval) at the shortest and longest durations was 0.4 ± 0.3 and 1.9 ± 1.1, respectively. At the longest durations, this corresponded to percent infarct volume reductions between 31.2% and 83.9%. Our analysis counters previous meta-analytic findings that there is no relationship, or an inverse relationship between TH duration and effect size. However, underreporting often led to high or unclear risks of bias for each study as gauged by the SYRCLE Risk of Bias tool. We also found a lack of investigations of the interactions between duration and other treatment considerations (e.g., method, delay, and ischemic severity). With consideration of methodological limitations, an understanding of the relationships between treatment parameters is necessary to determine proper "dosage" of TH, and should be further studied, considering clinical failures that contrast with strong cerebroprotective results in most animal studies.