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Kirian RD, Steinman D, Jewell CM, Zierden HC. Extracellular vesicles as carriers of mRNA: Opportunities and challenges in diagnosis and treatment. Theranostics 2024; 14:2265-2289. [PMID: 38505610 PMCID: PMC10945352 DOI: 10.7150/thno.93115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
Extracellular vesicles (EVs) are produced by all cells in the body. These biological nanoparticles facilitate cellular communication through the transport of diverse cargoes, including small molecules, proteins, and nucleic acids. mRNA cargoes have gained particular interest given their role in the translation of functional proteins. As a biomarker platform, EVs can be found in nearly all biofluids-blood, mucus, urine, cerebrospinal fluid, and saliva-providing real-time insight into parent cell and tissue function. mRNAs carried by EVs are protected from degradation, resulting in improved detection compared to free mRNA, and recent work demonstrates promising results in using these mRNA cargoes as biomarkers for cancer, neurological diseases, infectious diseases, and gynecologic and obstetric outcomes. Furthermore, given the innate cargo carrying, targeting, and barrier crossing abilities of EVs, these structures have been proposed as therapeutic carriers of mRNA. Recent advances demonstrate methods for loading mRNAs into EVs for a range of disease indications. Here, we review recent studies using EVs and their mRNA cargoes as diagnostics and therapeutics. We discuss challenges associated with EVs in diagnostic and therapeutic applications and highlight opportunities for future development.
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Affiliation(s)
- Robert D. Kirian
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, 20742
| | - Darby Steinman
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, 20742
| | - Christopher M. Jewell
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, 20742
- Department of Veterans Affairs, VA Maryland Health Care System, Baltimore, MD, USA
- Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, MD, 20742
- Robert E. Fischell Institute for Biomedical Devices, College Park, MD 20742, USA
| | - Hannah C. Zierden
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, 20742
- Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, MD, 20742
- Robert E. Fischell Institute for Biomedical Devices, College Park, MD 20742, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, 21201
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Dokuzović S, Španić M, Muthu S, Pavešić J, Ivandić S, Eder G, Bošnjak B, Prodan K, Lončar Z, Ćorluka S. Conservative Treatment for Spontaneous Resolution of Postoperative Symptomatic Thoracic Spinal Epidural Hematoma-A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1590. [PMID: 37763709 PMCID: PMC10534765 DOI: 10.3390/medicina59091590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/26/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023]
Abstract
Introduction: Postoperative epidural hematomas of the cervical and thoracic spine can pose a great risk of rapid neurological impairment and sometimes require immediate decompressive surgery. Case Report: We present the case of a young patient operated on for stabilization of a two-level thoracic vertebra fracture who developed total paralysis due to an epidural hematoma postoperatively. The course of epidural hematoma was quickly reversed with the help of a conservative technique that prevented revision surgery. The patient regained complete neurologic function very rapidly, and has been well on every follow-up to date. Conclusion: There is a role of similar maneuvers as described in this case to be employed in the management of postoperative epidural hematomas. However, prolonged watchful waiting should still be discouraged, and patients should remain ready for revision surgery if there are no early signs of rapid recovery.
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Affiliation(s)
- Stjepan Dokuzović
- Spinal Surgery Division, Department of Traumatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (S.D.); (J.P.)
- Akromion Special Hospital for Orthopaedic Surgery, 49217 Krapinske Toplice, Croatia;
| | - Mario Španić
- Akromion Special Hospital for Orthopaedic Surgery, 49217 Krapinske Toplice, Croatia;
| | - Sathish Muthu
- Orthopaedic Research Group, Coimbatore 641045, Tamil Nadu, India;
- Department of Biotechnology, Faculty of Engineering, Karpagam Academy of Higher Education, Coimbatore 641021, Tamil Nadu, India
- Department of Orthopaedics, Government Medical College, Karur 639004, Tamil Nadu, India
| | - Jure Pavešić
- Spinal Surgery Division, Department of Traumatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (S.D.); (J.P.)
| | - Stjepan Ivandić
- Traumatology Department, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia; (S.I.); (G.E.)
| | - Gregor Eder
- Traumatology Department, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia; (S.I.); (G.E.)
| | - Bogdan Bošnjak
- General Hospital, Croatian Veterans, 49210 Zabok, Croatia;
| | - Ksenija Prodan
- Clinical Department of Diagnostic and Interventional Radiology, Department of Traumatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia;
| | - Zoran Lončar
- Anesthesiology, Intensive Care and Pain Management Division, Traumatology Department, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia;
| | - Stipe Ćorluka
- Spinal Surgery Division, Department of Traumatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (S.D.); (J.P.)
- St. Catherine Specialty Hospital, 10000 Zagreb, Croatia
- Department of Anatomy and Physiology, University of Applied Health Sciences, 10000 Zagreb, Croatia
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3
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Tew ZY, Johnson D, Louis G, Bhowmick K. Purpura fulminans in a hyposplenic patient arising from pneumococcal sinusitis. BMJ Case Rep 2023; 16:e253043. [PMID: 37460246 PMCID: PMC10357718 DOI: 10.1136/bcr-2022-253043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
We report a previously healthy woman in her 50s who presented with sepsis, rapidly progressive purpuric rash and disseminated intravascular coagulation. She was diagnosed with acute infective purpura fulminans due to invasive pneumococcal infection likely secondary to sinusitis. Our case report discusses our initial diagnostic uncertainty and approach in investigating and treating such a critically unwell patient.
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Affiliation(s)
- Zi Yi Tew
- Department of Anaesthesia, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Daniel Johnson
- Department of General Medicine, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Gerard Louis
- Department of Emergency Medicine, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Kaushik Bhowmick
- Department of Anaesthesia, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
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4
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Safety of lumbar puncture for people who are treated with ADP receptor antagonists. J Neurol 2023; 270:3052-3057. [PMID: 36813930 DOI: 10.1007/s00415-023-11628-y] [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: 01/26/2023] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Current guidelines state that clopidogrel and other adenosine-diphosphate receptor antagonists (ADPra) should be stopped for at least 7 days before lumbar puncture (LP). This practice may delay the diagnosis of treatable neurological emergencies and may increase the risk of cardiovascular morbidity due to withholding antiplatelets. We aimed to summarize all cases under our care, in which LP was performed without discontinued ADPra. METHODS A retrospective case series study of all patients who underwent LP without interruption of ADPRa or with treatment interruption that was shorter than 7 days. Medical records were searched for documented complications. Traumatic tap was defined as cerebrospinal fluid red cell count ≥ 1000 cell/μL. Incidence of traumatic tap among people who underwent LP under ADPRa was compared to traumatic tap incidence in two control groups: LP under aspirin and LP without any anti-platelet. RESULTS 159 patients underwent LP under ADPRa [Age: 68.4 ± 12.1, Female: 63 (40%), 81 (51%) were treated with both aspirin and ADPRa]. 116 procedures were carried out without any interruption of ADPRa. In the other 43, the median delay between treatment interruption and the procedure was 2 days (range: 1-6 days). Incidence of traumatic tap was 8/159 (5%), 9/159 (5.7%) and 4/160 (2.5%) among those who underwent LP under ADPRa, under aspirin and without any anti-platelet, respectively. [X2(2) = 2.13, P = 0.35)]. No patient developed spinal hematoma or any neurological deficit. CONCLUSIONS Lumbar puncture without discontinuation of ADP receptor antagonists seems safe. Similar case series may ultimately lead to guidelines change.
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Spinal epidural hematoma in antiphospholipid syndrome: case report and review of the literature. Spinal Cord Ser Cases 2022; 8:11. [PMID: 35042850 PMCID: PMC8766459 DOI: 10.1038/s41394-022-00476-z] [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: 04/22/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Spinal epidural hematomas are a surgical emergency, the delay in diagnosis can develop devastating sequelae due to its acute and progressive course. If not treated properly, it may lead to death or permanent neurological deficit. It is a rare condition that can occur in patients with hematologic pathology. CASE PRESENTATION We report a case report and literature review of a patient with antiphospholipid syndrome, who undergoes a diagnostic lumbar puncture for probable fungal meningitis. Developed a spinal acute epidural hematoma with neurological involvement that is evidenced in MRI. Urgent surgical decompression was performed with good results. DISCUSSION Despite the low incidence of an epidural hematoma in patients who undergo lumbar puncture, it is important to perform a thorough evaluation in any patient with coagulation abnormalities prior and after a lumbar puncture, by reason of the inherent possibility of developing an epidural hematoma at the site of the procedure. In the same way, early diagnosis and aggressive treatment is necessary in patients who develop progressive neurological symptoms to limit the damage and improve the prognosis for neurological recovery.
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Nellis ME, Remy KE, Lacroix J, Cholette JM, Bembea MM, Russell RT, Steiner ME, Goobie SM, Vogel AM, Crighton G, Valentine SL, Delaney M, Parker RI. Research Priorities for Plasma and Platelet Transfusion Strategies in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e63-e73. [PMID: 34989706 PMCID: PMC8769351 DOI: 10.1097/pcc.0000000000002859] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present a list of high-priority research initiatives for the study of plasma and platelet transfusions in critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 13 experts developed research priorities for the study of plasma and platelet transfusions in critically ill children which were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. The specific priorities focused on the following subpopulations: severe trauma, traumatic brain injury, intracranial hemorrhage, cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, oncologic diagnosis or stem cell transplantation, acute liver failure and/or liver transplantation, noncardiac surgery, invasive procedures outside of the operating room, and sepsis and/or disseminated intravascular coagulation. In addition, tests to guide plasma and platelet transfusion, as well as component selection and processing, were addressed. We developed four general overarching themes and 14 specific research priorities using modified Research and Development/University of California, Los Angeles methodology. CONCLUSIONS Studies are needed to focus on the efficacy/harm, dosing, timing, and outcomes of critically ill children who receive plasma and/or platelet transfusions. The completion of these studies will facilitate the development of evidence-based recommendations.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jill M Cholette
- Division of Pediatric Critical Care Medicine, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam M Vogel
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, Australia
| | - Stacey L Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital; Department of Pathology and Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Robert I Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
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Disseminated Intravascular Coagulation Is an Independent Predictor of Adverse Outcomes in Children in the Emergency Department with Suspected Sepsis. J Pediatr 2020; 225:198-206.e2. [PMID: 32553867 PMCID: PMC7529972 DOI: 10.1016/j.jpeds.2020.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/03/2020] [Accepted: 06/06/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the impact of early disseminated intravascular coagulation (DIC) on illness severity in children using a database of emergency department ED encounters for children with suspected sepsis, in view of similar associations in adults. STUDY DESIGN Laboratory and clinical data were extracted from a registry of emergency department encounters of children with suspected sepsis between April 1, 2012, and June 26, 2017. International Society of Thrombosis and Hemostasis DIC scores were calculated from laboratory values obtained within 24 hours of emergency department admission. Univariate logistic regression, multivariable logistic regression, and Cox regression were used to assess the influence of DIC scores on vasopressor use (primary outcome), mortality, ventilator requirement, pediatric intensive care unit admission, and hospital duration (secondary outcomes). The optimal DIC score cutoff for outcome prediction was determined. RESULTS Of 1653 eligible patients, 284 had DIC scores within 24 hours, including 92 who required vasopressors and 23 who died within 1 year. An initial DIC score of ≥3 was the most sensitive and specific DIC score for predicting adverse outcomes. Those with a DIC score of ≥3 vs <3 had increased odds of vasopressor use in both univariate (OR, 4.48; 95% CI, 2.63-7.62; P < .001) and multivariable (OR, 3.78; 95% CI, 1.82-7.85; P < .001) analyses. Additionally, those with a DIC score of ≥3 vs <3 had increased 1-year mortality with a hazard ratio of 3.55 (95% CI, 1.46-8.64; P = .005). CONCLUSIONS A DIC score of ≥3 was an independent predictor for both vasopressor use and mortality in this pediatric cohort, distinct from the adult overt DIC score cutoff of ≥5.
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Aboumerhi H, Elmofty DH. Self-Limited Spinal Subarachnoid Hemorrhage After Lumbar Spinal Drain Removal While on Clopidogrel: A Case Report. A A Pract 2019; 13:436-439. [PMID: 31577536 DOI: 10.1213/xaa.0000000000001104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spinal subarachnoid hemorrhage (SSH) is a rare yet potentially devastating complication of neuraxial procedures. We present a case of SSH after inadvertent lumbar spinal drain removal while on clopidogrel. The contrast between the patient's mild clinical symptoms compared to his impressive magnetic resonance imaging (MRI) highlights the variable presentations that can be seen with spinal and epidural hematomas. Despite sophisticated electronic warnings systems available to improve patient safety, better efforts are needed to improve interprofessional communication with providers taking care of patients with indwelling neuraxial catheters.
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Affiliation(s)
- Hassan Aboumerhi
- From the Department of Anesthesiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Dalia H Elmofty
- Department of Anesthesiology, University of Chicago, Chicago, Illinois
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9
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Qi M, Huang T, Xu L, Wang N, Zhang P, Hu X. A Spinal Subdural Hematoma Induced by Guidewire-based Lumbar Drainage in a Patient with Ruptured Intracranial Aneurysms. Open Med (Wars) 2019; 14:247-250. [PMID: 30847402 PMCID: PMC6401395 DOI: 10.1515/med-2019-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/28/2019] [Indexed: 11/25/2022] Open
Abstract
We present a rare case of spinal subdural hematoma induced by guidewire-based lumbar drainage in a subarachnoid hemorrhage patient with a ruptured intracranial aneurysm. Decreased muscle strength and muscle tension of bilateral lower limbs were noted, and an MRI confirmed the spinal subdural hematoma from the sacral to the thoracic segments. The spinal subdural hematoma evacuation and spinal canal decompression were performed by laminectomy. However, the patient did not benefit from the surgery and developed lower limb muscle atrophy. The complication of the spinal subdural hematoma after lumbar drainage is extremely rare; only limited approaches are available for the treatment of spinal hematoma to improve the outcome and avoid severe consequences. Thus, the present case might suggest refraining from use of a guidewire during lumbar drainage for the prevention of spinal subdural hematoma and close observation of the related symptoms and signs for the early detection of spinal hematoma after the procedure. In addition, full decompression can be performed by complete hematoma evacuation and laminectomy of related segments for the treatment of spinal subdural hematoma induced by lumbar drainage.
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Affiliation(s)
- Meng Qi
- Department of Neurosurgery, Chongqing Emergency Medical Center, The Fourth People’s Hospital of Chongqing, No.1 Jiankang Road, Yuzhong District, Chongqing 400014, Chongqing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Huang
- Department of Neurosurgery, Chongqing Emergency Medical Center, The Fourth People’s Hospital of Chongqing, No.1 Jiankang Road, Yuzhong District, Chongqing 400014, Chongqing, China
| | - Lei Xu
- Department of Neurosurgery, Chongqing Emergency Medical Center, The Fourth People’s Hospital of Chongqing, No.1 Jiankang Road, Yuzhong District, Chongqing 400014, Chongqing, China
| | - Ning Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Peipei Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Hangzhou, China
- Tel: +86-571-87070910, Fax: +86-57187070910
| | - Xi Hu
- Department of Neurosurgery, Chongqing Emergency Medical Center, The Fourth People’s Hospital of Chongqing, No.1 Jiankang Road, Yuzhong District, Chongqing 400014, Chongqing, China
- Tel: +86-571-87070910, Fax: +86-57187070910
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10
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Yedavalli V, Jain MS, Das D, Massoud TF. Are high lumbar punctures safe? A magnetic resonance imaging morphometric study of the conus medullaris. Clin Anat 2019; 32:618-629. [PMID: 30807670 DOI: 10.1002/ca.23359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/22/2019] [Accepted: 02/24/2019] [Indexed: 11/11/2022]
Abstract
A high lumbar puncture (LP) at L2-L3 or above is often necessary to consider on technical grounds, but complications of conus medullaris (CM) damage during high LP are potentially concerning. We hypothesized that a high LP might be safer than previously thought by accounting for movements of the CM upon patient positional changes. We retrospectively reviewed standard normal supine lumbar spine magnetic resonance imaging of 58 patients and used electronic calipers on axial images at the T12-L1, L1-L2, and L2-L3 disc levels to measure the transverse diameter of the CM relative to the size of the dorsal thecal sac space (DTSS) through which a spinal needle could be inserted. On 142 axial images, the means for CM diameters were 8.2, 6.0, and 2.9 mm at the three levels, respectively. We then used known literature mean CM displacement values in the legs flexed and unflexed lateral decubitus position (LDP) to factor in CM shifts to the dependent side. We found that at all three levels, the likely positional shift of the CM would be too small and insufficient to displace the entire CM out of the DTSS. However, if needle placement could be confined to the midsagittal plane, an LP in the unflexed LDP would theoretically be entirely safe at both L1-L2 and L2-L3, and almost so at L2-L3 in the legs flexed LDP. Thus, high LPs at L1-L2 and L2-L3 are in theory likely safer than considered previously, more so in the legs unflexed than in the flexed LDP. Clin. Anat. 32:618-629, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Vivek Yedavalli
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Mika S Jain
- Department of Physics, Stanford University School of Humanities and Sciences, Stanford, California.,Department of Computer Science, Stanford University School of Engineering, Stanford, California
| | - Devsmita Das
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Tarik F Massoud
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California.,Section of Neuroradiology, Department of Radiology, Addenbrooke's Hospital, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
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11
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Costerus JM, Brouwer MC, van de Beek D. Technological advances and changing indications for lumbar puncture in neurological disorders. Lancet Neurol 2019; 17:268-278. [PMID: 29452686 DOI: 10.1016/s1474-4422(18)30033-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/24/2017] [Accepted: 11/28/2017] [Indexed: 01/12/2023]
Abstract
Technological advances have changed the indications for and the way in which lumbar puncture is done. Suspected CNS infection remains the most common indication for lumbar puncture, but new molecular techniques have broadened CSF analysis indications, such as the determination of neuronal autoantibodies in autoimmune encephalitis. New screening techniques have increased sensitvity for pathogen detection and can be used to identify pathogens that were previously unknown to cause CNS infections. Evidence suggests that potential treatments for neurodegenerative diseases, such as Alzheimer's disease, will rely on early detection of the disease with the use of CSF biomarkers. In addition to being used as a diagnostic tool, lumbar puncture can also be used to administer intrathecal treatments as shown by studies of antisense oligonucleotides in patients with spinal muscular atrophy. Lumbar puncture is generally a safe procedure but complications can occur, ranging from minor (eg, back pain) to potentially devastating (eg, cerebral herniation). Evidence that an atraumatic needle tip design reduces complications of lumbar puncture is compelling, and reinforces the need to change clinical practice.
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Affiliation(s)
- Joost M Costerus
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands.
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12
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Kolipaka A, Wassenaar PA, Cha S, Marashdeh WM, Mo X, Kalra P, Gans B, Raterman B, Bourekas E. Magnetic resonance elastography to estimate brain stiffness: Measurement reproducibility and its estimate in pseudotumor cerebri patients. Clin Imaging 2018; 51:114-122. [PMID: 29459315 PMCID: PMC6087505 DOI: 10.1016/j.clinimag.2018.02.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 01/08/2018] [Accepted: 02/02/2018] [Indexed: 01/01/2023]
Abstract
This study determines the reproducibility of magnetic resonance elastography (MRE) derived brain stiffness in normal volunteers and compares it against pseudotumor patients before and after lumbar puncture (LP). MRE was performed on 10 normal volunteers for reproducibility and 14 pseudotumor patients before and after LP. During LP, opening and closing cerebrospinal fluid (CSF) pressures were recorded before and after removal of CSF and correlated to brain stiffness. Stiffness reproducibility was observed (r > 0.78; p < 0.008). Whole brain opening LP stiffness was significantly (p = 0.04) higher than normals, but no significant difference (p = 0.11) in closing LP measurements. No significant correlation was observed between opening and closing pressure and brain stiffness.
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Affiliation(s)
- Arunark Kolipaka
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Peter A Wassenaar
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sangmin Cha
- Electrical and Computer Engineering, The Ohio State University, Columbus, OH, USA
| | - Wael M Marashdeh
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Xiaokui Mo
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Prateek Kalra
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bradley Gans
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Brian Raterman
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eric Bourekas
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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13
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Dodd KC, Emsley HCA, Desborough MJR, Chhetri SK. Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists clinical guideline. Pract Neurol 2018; 18:436-446. [DOI: 10.1136/practneurol-2017-001820] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2018] [Indexed: 11/04/2022]
Abstract
Lumbar puncture (LP) is an important and frequently performed invasive procedure for the diagnosis and management of neurological conditions. There is little in the neurological literature on the topic of periprocedural management of antithrombotics in patients undergoing LP. Current practice is therefore largely extrapolated from guidelines produced by anaesthetic bodies on neuraxial anaesthesia, haematology groups advising on periprocedural management of antiplatelet agents and anticoagulants, and by neuroradiology on imaging-guided spinal procedures. This paper summarises the existing literature on the topic and offers recommendations to guide periprocedural antithrombotic management for LP, based on the consolidation of the best available evidence.
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Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018; 48:1048-1065. [PMID: 29796797 DOI: 10.1007/s00247-018-4149-1] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/22/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.
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Affiliation(s)
- Arabinda Kumar Choudhary
- Department of Radiology, Nemours AI duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Sabah Servaes
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas L Slovis
- Department of Radiology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | | | - Gary L Hedlund
- Department of Medical Imaging, Primary Children's Hospital, Intermountain Healthcare, Department of Radiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sandeep K Narang
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Mark S Dias
- Departments of Neurosurgery and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Cindy W Christian
- Department of Pediatrics, Child Abuse and Neglect Prevention, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Marvin D Nelson
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | | | - Susan Palasis
- Pediatric Neuroradiology, Children's Healthcare of Atlanta, Scottish Rite Campus, Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Andrea Rossi
- Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Amaka C Offiah
- Paediatric Musculoskeletal Imaging, Academic Unit of Child Health, Sheffield Children's NHS Foundation Trust, Western Bank, University of Sheffield, Sheffield, UK
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Singh V, Patel S, Singh K. Unexpected intrathecal haemorrhage following uncomplicated placement and removal of an epidural catheter. BJR Case Rep 2018; 4:20170108. [PMID: 31489213 PMCID: PMC6711277 DOI: 10.1259/bjrcr.20170108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 04/10/2018] [Accepted: 04/11/2018] [Indexed: 12/27/2022] Open
Abstract
We report a case of intrathecal and epidural haemorrhage 2 weeks after
uncomplicated placement and removal of an epidural catheter in a patient that
was initially scheduled for surgical repair of an aortic dissection and
aneurysm. Included in this case report is a literature review and discussion of
similar entities, differential diagnoses, and high yield learning points.
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Affiliation(s)
- Vivek Singh
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, VA, USA
| | - Sumir Patel
- Department of Radiology, Emory University Hospital, Atlanta, Georgia, GA, USA
| | - Kush Singh
- Department of Radiology, Emory University Hospital, Atlanta, Georgia, GA, USA
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16
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Al Jishi A, Murty N. Massive lumbar spine hematoma post-spinal tap. Surg Neurol Int 2017; 8:293. [PMID: 29285409 PMCID: PMC5735427 DOI: 10.4103/sni.sni_351_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/05/2017] [Indexed: 01/30/2023] Open
Abstract
Background: Lumbar puncture is a well-known procedure. The indications for lumbar puncture vary among different medical and surgical disciplines, though obtaining a sample for cerebrospinal fluid analysis is the most common one. A normal coagulation profile is crucial prior to pursing the procedure. Occasionally, an urgent sample is needed to guide an appropriate treatment while the patient's coagulation status is suboptimum. In those specific critical situations, some may accept suboptimal correction owing to the urgency of the case. Case Description: We report a case for a patient with Burkitt lymphoma who presented with mild neuroaxial symptoms. An urgent cerebrospinal fluid sample was required which was taken after correcting his platelets count to 53.4 × 109/L. He developed a massive multi-compartmental thoracolumbar hematoma with acute cauda equine syndrome requiring surgical intervention. Despite aggressive management, he remained permanently paraplegic with functional status that negatively affected his overall outcome. Conclusion: Lumbar puncture is a useful diagnostic and treatment tool. Although serious events are seldom, they can be detrimental. A precaution not to underestimate such events in practicing lumbar, especially in patients with suboptimum coagulation state. Image-guided procedure can be useful and should be considered in appropriately selected patients.
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Affiliation(s)
- Ahmed Al Jishi
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Naresh Murty
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
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17
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Melegari G, Taddia G, Manenti A, Barbieri A. Epidural catheter cutting: mechanisms and management. J Clin Anesth 2017; 39:75-76. [PMID: 28494913 DOI: 10.1016/j.jclinane.2017.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/09/2017] [Indexed: 11/19/2022]
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18
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Deer TR, Pope JE, Hayek SM, Lamer TJ, Veizi IE, Erdek M, Wallace MS, Grider JS, Levy RM, Prager J, Rosen SM, Saulino M, Yaksh TL, De Andrés JA, Abejon Gonzalez D, Vesper J, Schu S, Simpson B, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks. Neuromodulation 2017; 20:155-176. [DOI: 10.1111/ner.12579] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/22/2016] [Accepted: 12/07/2016] [Indexed: 01/12/2023]
Affiliation(s)
| | | | - Salim M. Hayek
- University Hospitals Cleveland Medical Center, Case Western Reserve University; Cleveland OH USA
| | | | - Ilir Elias Veizi
- Veterans Administration Medical Center, Case Western Reserve University; Cleveland OH USA
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- UK HealthCare Pain Services, University of Kentucky College of Medicine; Lexington KY USA
| | | | - Joshua Prager
- Center for the Rehabilitation of Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology, University of California; San Diego CA USA
| | - Jose A. De Andrés
- Valencia School of Medicine, Hospital General Universitario; Valencia Spain
| | | | - Jan Vesper
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf; Germany
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
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