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Rizk AA, Venkatraghavan L, Shankar JJS, Schaller B, Chowdhury T. Reappearance of Neurological Deficits in Pathologic Brain: Are Sedatives and Opioids Culprits? A Systematic Review. J Neurosurg Anesthesiol 2022; 34:14-20. [PMID: 34116547 DOI: 10.1097/ana.0000000000000785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/11/2021] [Indexed: 11/26/2022]
Abstract
Following a brain insult, focal neurological deficits may develop. Despite resolution of these deficits with time, the subsequent administration of sedative medications and opioids may lead to recrudescence of previous neurological deficits. Therefore, the present systematic review aims to explore the role of different sedatives and opioid analgesics at reproducing focal neurological deficits in patients with previous brain insults undergoing surgery. Our PRISMA compliant systematic review covering the literature from 1990 to 2020 showed a consistent reoccurrence of neurological deficits following administration of benzodiazepines and opioids across 12 studies. It appears that in all studies, the manifestations were transient and affected mostly middle-aged patients (45 to 67 y of age). In addition, benzodiazepines and opioid antagonism by naloxone and flumazenil reverses the unmasking of prior neurological deficits. In contrast, it is not clear based on our study whether the unmasking or worsening of neurological deficits occurs following recent injuries or an older brain insult, although for most patients it appears to be the former. Future studies are needed to elucidate the mechanisms involved in unmasking prior deficits and/or extension of prior injuries by sedative and opioid analgesics. This review will aid in developing prospective studies on individual sedative medications and their effects on unmasking neurological deficits in patients with multiple brain pathologies.
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Affiliation(s)
| | - Lashmi Venkatraghavan
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, Toronto, ON
| | - Jai J S Shankar
- Section Intervention Neuroradiology, Department of Radiology, University of Manitoba, Winnipeg, MB, Canada
| | - Bernhard Schaller
- Department of Pathology, Institute of Cardiovascular Physiopathology, University of Buenos Aires, Buenos Aires, Argentina
| | - Tumul Chowdhury
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, Toronto, ON
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Akamatsu Y, Chaitin HJ, Hanafy KA. Post-stroke recrudescence-a possible connection to autoimmunity? Rev Neurosci 2021; 33:207-212. [PMID: 34363383 DOI: 10.1515/revneuro-2021-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/27/2021] [Indexed: 11/15/2022]
Abstract
Early recanalization of the occluded vessel is the only efficient intervention that improves outcome after ischemic stroke. In contrast, interventions for chronic issues facing stroke patients are limited. Recent clinical and preclinical studies have shown a correlation between upregulated immune responses to brain antigens and post-stroke recrudescence (PSR), post-stroke fatigue (PSF), and dementia (PSD); all of which are associated with poor long-term stroke outcome. Recent retrospective studies have demonstrated a strong correlation between the onset of PSR and acute infection during acute stroke, suggesting some adaptive immune system mediated pathology. This review will discuss the mechanisms and epidemiology of PSR based on the current clinical and pre-clinical evidence. Accordingly, PSR does appear correlated with populations that are prone to autoimmunity, infection, and subsequent triggers, which corroborate autoimmune responses to self-brain antigens as an underlying mechanism. Moreover, PSR as well as PSF and PSD seem to be partly explained by the development of a neuro-inflammatory response to brain antigens. Therefore, the future of improving long-term stroke outcome could be bright with more accurate pre-clinical models focusing on the role of adaptive immune-mediated post stroke neuroinflammation and more clinical studies of PSR.
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Affiliation(s)
- Yosuke Akamatsu
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA02215, USA.,Department of Neurosurgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate020-0023, Japan
| | - Hersh J Chaitin
- College of Medicine, Florida Atlantic University, 777 Glades Rd., Boca Raton, FL33431, USA
| | - Khalid A Hanafy
- College of Medicine, Florida Atlantic University, 777 Glades Rd., Boca Raton, FL33431, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA02215, USA.,Division of Neurocritical Care, Marcus Neuroscience Institute, Boca Raton Medical Center, Boca Raton, FL, USA
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Abstract
Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.
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Affiliation(s)
- Eliza C Miller
- From the Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Lisa Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Minhas JS, Rook W, Panerai RB, Hoiland RL, Ainslie PN, Thompson JP, Mistri AK, Robinson TG. Pathophysiological and clinical considerations in the perioperative care of patients with a previous ischaemic stroke: a multidisciplinary narrative review. Br J Anaesth 2020; 124:183-196. [PMID: 31813569 PMCID: PMC7034810 DOI: 10.1016/j.bja.2019.10.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/24/2019] [Accepted: 10/18/2019] [Indexed: 12/28/2022] Open
Abstract
With an ageing population and increasing incidence of cerebrovascular disease, an increasing number of patients presenting for routine and emergency surgery have a prior history of stroke. This presents a challenge for pre-, intra-, and postoperative management as the neurological risk is considerably higher. Evidence is lacking around anaesthetic practice for patients with vascular neurological vulnerability. Through understanding the pathophysiological changes that occur after stroke, insight into the susceptibilities of the cerebral vasculature to intrinsic and extrinsic factors can be developed. Increasing understanding of post-stroke systemic and cerebral haemodynamics has provided improved outcomes from stroke and more robust secondary prevention, although this knowledge has yet to be applied to our delivery of anaesthesia in those with prior stroke. This review describes the key pathophysiological and clinical considerations that inform clinicians providing perioperative care for patients with a prior diagnosis of stroke.
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Affiliation(s)
- Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Research Group, Leicester Biomedical Research Centre, University of Leicester, Leicester, UK.
| | - William Rook
- Academic Department of Anaesthesia, Critical Care, Pain, and Resuscitation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ronney B Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Research Group, Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research, Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ryan L Hoiland
- Centre for Heart, Lung, and Vascular Health, University of British Columbia, Kelowna, BC, Canada
| | - Phil N Ainslie
- Centre for Heart, Lung, and Vascular Health, University of British Columbia, Kelowna, BC, Canada
| | - Jonathan P Thompson
- Anaesthesia and Critical Care, Department of Cardiovascular Sciences, Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - Amit K Mistri
- University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - Thompson G Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Research Group, Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research, Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
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Jun-O'connell AH, Henninger N, Moonis M, Silver B, Ionete C, Goddeau RP. Recrudescence of Old Stroke Deficits Among Transient Neurological Attacks. Neurohospitalist 2019; 9:183-189. [PMID: 31534606 DOI: 10.1177/1941874419829288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Recrudescence of old stroke deficits (ROSD) is a reported cause of transient neurological symptoms, but it is not well characterized. Objective We sought to determine the prevalence, potential triggers, and clinical outcome of ROSD in a cohort of patients presenting with acute transient neurological attack (TNA) and absent acute pathology on brain imaging. Methods We retrospectively analyzed 340 consecutive patients who presented with TNA and no acute pathology on brain imaging that were included in an institutional stroke registry between February 2013 and April 2015. The presumed TNA cause was categorized as transient ischemic attack (TIA), ROSD, and other cause. Baseline characteristics, triggers, cardiovascular complications within 90 days, and death were recorded. Results The prevalence of ROSD in the studied cohort was 10% (34/340). Infectious stressors and acute metabolite derangements were more common in ROSD compared to TIA (P < .05, each). Compared to TIA and the other TNA, ROSD was more likely to have more than 1 acute stressor (P < .001). Patients with ROSD had similar vascular risk factors compared to TIA (P > .05), including hypertension, diabetes mellitus, peripheral vascular disease, hyperlipidemia, and similarly used HMG-CoA reductase inhibitor, antihypertensive, and antiplatelet medications. Among the patients with an available 90-day follow-up (n = 233), cardiovascular events were more frequent in the TIA group as compared to other TNA (P < .05). Conclusion ROSD is common and distinct from TIA and is associated with a triggering physiologic reaction leading to transient reemergence of prior neurologic deficits. Further study of the mechanism of this phenomenon is needed to help better identify these patients.
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Affiliation(s)
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Carolina Ionete
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Richard P Goddeau
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
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Xie W, Xie W, Kang Z, Jiang C, Liu N. Hydromorphone protects CA1 neurons by activating mTOR pathway. Neurosci Lett 2018; 687:49-54. [DOI: 10.1016/j.neulet.2018.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/14/2018] [Accepted: 09/15/2018] [Indexed: 12/20/2022]
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Topcuoglu MA, Saka E, Silverman SB, Schwamm LH, Singhal AB. Recrudescence of Deficits After Stroke: Clinical and Imaging Phenotype, Triggers, and Risk Factors. JAMA Neurol 2017; 74:1048-1055. [PMID: 28783808 DOI: 10.1001/jamaneurol.2017.1668] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Reemergence of previous stroke-related deficits (or poststroke recrudescence [PSR]) is an underrecognized and inadequately characterized phenomenon. Objective To investigate the clinical features, triggers, and risk factors for PSR. Design, Setting, and Participants This retrospective study incorporated a crossover cohort study to identify triggers and a case-control study to identify risk factors. The study used the Massachusetts General Hospital Research Patient Data Repository to identify patients for the period January 1, 2000, to November 30, 2015, who had a primary or secondary diagnosis of cerebrovascular disease, who underwent magnetic resonance imaging of the brain at least once, and whose inpatient or outpatient clinician note or discharge summary stated the term recrudescence. In all, 153 patients met the preliminary diagnostic criteria for PSR: transient worsening of residual poststroke focal neurologic deficits or transient recurrence of prior stroke-related focal deficits, admission magnetic resonance imaging showing a chronic stroke but no acute infarct or hemorrhage, no evidence of transient ischemic attack or seizure, no acute lesion on diffusion-weighted imaging, and no clinical or electroencephalographic evidence of seizure around the time of the event. Main Outcomes and Measures Clinical and imaging features of PSR; triggers (identified by comparing PSR admissions with adjacent admissions without PSR); and risk factors (identified by comparing PSR cases with control cases from the Massachusetts General Hospital Stroke Registry). Results Of the 153 patients, 145 had prior infarct, 8 had hypertensive brain hemorrhage, and 164 admissions for PSR were identified. The patients' mean (SD) age was 67 (16) years, and 92 (60%) were women. Recrudescence occurred a mean (SD) of 3.9 (0.6) years after the stroke, lasted 18.4 (20.4) hours, and was resolved on day 1 for 91 of the 131 episodes with documented resolution time (69%). Deficits were typically abrupt and mild and affected motor-sensory or language function. No patient had isolated gaze paresis, hemianopia, or neglect. During PSR, the National Institutes of Health Stroke Scale (NIHSS) score worsened by a mean (SD) 2.5 (1.9) points, and deficits were limited to a single NIHSS item in 62 episodes (38%). The underlying chronic strokes were variably sized, predominantly affected white matter tracts, and involved the middle cerebral artery territory for 112 patients (73%). Infection, hypotension, hyponatremia, insomnia or stress, and benzodiazepine use were higher during PSR admissions. Compared with the control group (patients who did not experience recrudescence), the PSR group (patients who were hospitalized for recrudescence) had more women, African American individuals, and those who self-identified as being from "other" race. The PSR group also had more diabetes, dyslipidemia, smoking, infarcts from small-vessel disease, and "other definite" causes and worse onset NIHSS scores. Six patients (4%) received intravenous tissue plasminogen activator without complications. Conclusions and Relevance The PSR features identified in the study should enable prompt diagnosis and distinguish recrudescence from mimics, such as transient ischemic attacks, migraine, Todd paralysis, and Uhthoff phenomenon. Prospective studies are required to validate the proposed diagnostic criteria and to decipher underlying mechanisms.
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Affiliation(s)
- Mehmet A Topcuoglu
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston.,Neurology Department, Hacettepe University Hospitals, Ankara, Turkey
| | - Esen Saka
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston.,Neurology Department, Hacettepe University Hospitals, Ankara, Turkey
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
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Recrudescence of Symptoms of Remote Ischemic Stroke After a Cerebral Angiogram. World Neurosurg 2017; 101:814.e15-814.e17. [DOI: 10.1016/j.wneu.2017.02.122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 11/23/2022]
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