Myeloperoxidase to high-density lipoprotein ratio: Potential predictor of severity and outcome in patients with acute ischemic stroke

OBJECTIVE

As a new marker of inflammation and lipid metabolism, the ratio of myeloperoxidase to high density lipoprotein (MPO/HDL) has been reported in the field of cardiovascular disease. However, the effect of MPO/HDL on acute ischemic stroke (AIS) is not clear. The purpose of this study was to explore the prognostic value of MPO/HDL level in patients with AIS.

METHODS

This study conducted a retrospective analysis of 363 patients diagnosed with AIS. Stroke severity was assessed by National Institutes of Health Stroke Scale (NIHSS). The short-term functional outcome was evaluated with modified Rankin Scale (mRS) 90 days after admission. Spearman correlation analysis was used to evaluate the correlation between MPO/HDL and NIHSS scores. The predictive value of MPO, HDL and MPO/HDL to AIS was evaluated by receiver operating characteristic curve (ROC).

RESULTS

The level of MPO/HDL in patients with NIHSS score ≥ 4 was significantly higher than that in patients with NIHSS score < 4 (P < 0.001). MPO and MPO/HDL were positively correlated with NIHSS score (P < 0.001), while HDL was negatively correlated with NIHSS score (P < 0.001). During 90-day follow-up, multivariate Logistic regression analysis showed that increased MPO/HDL levels were associated with 90-day functional outcomes. ROC showed that compared with MPO and HDL, MPO/HDL had the highest predictive value for 90-day functional prognosis in patients with AIS (AUC = 0.9825).

CONCLUSION

The level of serum MPO/HDL may be potential prognostic biomarker in AIS 90 days.

Does Magnetic Resonance Imaging Predict Neurological Deficit in Patients with Traumatic Lower Lumbar Fractures?

STUDY DESIGN

A retrospective cohort study.

PURPOSE

This study aimed to understand the role of magnetic resonance imaging (MRI) in predicting neurological deficits in traumatic lower lumbar fractures (LLFs; L3-L5).

OVERVIEW OF LITERATURE

Despite studies on the radiological risk factors for neurological deficits in thoracolumbar fractures, very few have focused on LLFs. Moreover, the potential utility of MRI in LLFs has not been evaluated.

METHODS

In total, 108 patients who underwent surgery for traumatic LLFs between January 2010 and January 2020 were reviewed to obtain their demographic details, injury level, and neurology status at the time of presentation (American Spinal Injury Association [ASIA] grade). Preoperative computed tomography scans were used to measure parameters such as anterior vertebral body height, posterior vertebral body height, loss of vertebral body height, local kyphosis, retropulsion of fracture fragment, interpedicular distance, canal compromise, sagittal transverse ratio, and presence of vertical lamina fracture. MRI was used to measure the canal encroachment ratio (CER), cross-sectional area of the thecal sac (CSAT), and presence of an epidural hematoma.

RESULTS

Of the 108 patients, 9 (8.3%) had ASIA A, 4 (3.7%) had ASIA B, 17 (15.7%) had ASIA C, 21 (19.4%) had ASIA D, and 57 (52.9%) had ASIA E neurology upon admission. The Thoracolumbar Injury Classification and Severity score (p =0.000), CER (p =0.050), and CSAT (p =0.019) were found to be independently associated with neurological deficits on the multivariate analysis. The receiver operating characteristic curves showed that only CER (area under the curve [AUC], 0.926; 95% confidence interval [CI], 0.860-0.968) and CSAT (AUC, 0.963; 95% CI, 0.908-0.990) had good discriminatory ability, with the optimal cutoff of 50% and 65.3 mm2, respectively.

CONCLUSIONS

Based on the results, the optimal cutoff values of CER >50% and CSAT >65.3 mm2 can predict the incidence of neurological deficits in LLFs.

Assessment of sepsis-associated encephalopathy by quantitative magnetic resonance spectroscopy in a rat model of cecal ligation and puncture

Proton magnetic resonance spectroscopy (1H-MRS) is the only non-invasive technique to quantify neurometabolic compounds in the living brain. We used 1H-MRS to evaluate the brain metabolites in a rat model of Sepsis-associated encephalopathy (SAE) established by cecal ligation and puncture (CLP). 36 male Sprague-Dawley rats were randomly divided into sham and CLP groups. Each group was further divided into three subgroups: subgroup O, subgroup M, and subgroup N. Neurological function assessments were performed on the animals in the subgroup O and subgroup N at 24 h, 48 h, and 72 h. The animals in the subgroup M were examined by magnetic resonance imaging (MRI) at 12 h after CLP. Compared with the sham group, the ratio of N-acetylaspartate (NAA) to creatine (Cr) in the hippocampus was significantly lower in the CLP group. The respective ratios of lactate (Lac), myo-inositol (mIns), glutamate and glutamine (Glx), lipid (Lip), and choline (Cho) to Cr in the CLP group were clearly higher than those in the sham group. Cytochrome c, intimately related to oxidative stress, was elevated in the CLP group. Neurofilament light (NfL) chain and glial fibrillary acidic protein (GFAP) scores in the CLP group were significantly higher than those in the sham group, while zonula occludens-1 (ZO-1) was downregulated. Compared with the sham group, the CLP group displayed higher values of oxygen extraction fraction (OEF), central venous-arterial partial pressure of carbon dioxide (P (cv-a) CO2), and central venous lactate (VLac). In contrast, jugular venous oxygen saturation (SjvO2) declined. In the present study, 1H-MRS could be used to quantitatively assess brain injury in terms of microcirculation disorder, oxidative stress, blood-brain barrier disruption, and glial cell activation through changes in metabolites within brain tissue.

What Factors Predict the Development of Neurologic Deficits Following Resection of Intramedullary Spinal Cord Tumors: A Multi-Center Study

BACKGROUND

Intramedullary spinal cord tumors are challenging to resect, and their postoperative neurological outcomes are often difficult to predict, with few studies assessing this outcome.

METHODS

We reviewed the medical records of all patients surgically treated for Intramedullary spinal cord tumors at our multisite tertiary care institution (Mayo Clinic Arizona, Mayo Clinic Florida, Mayo Clinic Rochester) between June 2002 and May 2020. Variables that were significant in the univariate analyses were included in a multivariate logistic regression. "MissForest" operating on the Random Forest algorithm, was used for data imputation, and K-prototype was used for data clustering. Heatmaps were added to show correlations between postoperative neurological deficit and all other included variables. Shapley Additive exPlanations were implemented to understand each feature's importance.

RESULTS

Our query resulted in 315 patients, with 160 meeting the inclusion criteria. There were 53 patients with astrocytoma, 66 with ependymoma, and 41 with hemangioblastoma. The mean age (standard deviation) was 42.3 (17.5), and 48.1% of patients were women (n = 77/160). Multivariate analysis revealed that pathologic grade >3 (OR = 1.55; CI = [0.67, 3.58], P = 0.046 predicted a new neurological deficit. Random Forest algorithm (supervised machine learning) found age, use of neuromonitoring, histology of the tumor, performing a midline myelotomy, and tumor location to be the most important predictors of new postoperative neurological deficits.

CONCLUSIONS

Tumor grade/histology, age, use of neuromonitoring, and myelotomy type appeared to be most predictive of postoperative neurological deficits. These results can be used to better inform patients of perioperative risk.

Intra-operative Neurophysiological Monitoring in Patients Undergoing Posterior Spinal Correction Surgery with Pre-operative Neurological Deficit: Its Feasibility and High-risk Factors for Failed Monitoring

OBJECTIVE

Considering spinal deformity patients with pre-operative neurological deficit were associated with more intra-operative iatrogenic neurological complications than those without, intra-operative neurophysiological monitoring (IONM) has been used for detecting possible iatrogenic injury timely. However, the IONM waveforms are often unreliable. To analyze the performance of intra-operative neurophysiological monitoring (IONM) including somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) in patients with pre-operative neurological deficit undergoing posterior spinal correction surgery, and to identify the high-risk factors for failed IONM.

METHODS

Patients with pre-operative neurological deficit undergoing posterior spinal correction surgery between October 2017 and January 2022 were retrospectively reviewed. The presence or absence of SEP and MEP of target muscles were separately recorded. The P37/N50 latency and amplitude of SEP, and the MEP amplitude were measured. Any IONM alerts were also recorded. The IONM performance was compared among patients with different etiologies, levels responsible for neurological deficit, and strength of IONM-target muscles. Patients' demographics were analyzed using the descriptive statistics and were presented with mean ± standard deviation. Comparison analysis was performed using χ2 -test and statistically significant difference was defined as p < 0.05.

RESULTS

A total of 270 patients (147 males, 123 females) with an average age of 48.4 ± 36.7 years were involved. The SEP records were available in 371 (68.7%) lower extremities while MEP records were available in 418 (77.4%). SEP alerts were reported in 31 lower extremities and MEP alerts in 22, and new neurological deficit at post-operation was observed in 11. The etiologies of neuromuscular and syndromic indicated relatively lower success rates of IONM, which were 44.1% and 40.5% for SEP, and 58.8% and 59.5% for MEP (p < 0.001). In addition, patients with pre-operative neurological deficit caused by cervical spine and muscle strength lower than grade 4 suffered from higher risk of failed IONM waveforms (p < 0.001).

CONCLUSION

Patients with pre-operative neurological deficit suffered from a higher incidence of failed IONM results. The high-risk for failed IONM waveforms included the neuromuscular and syndromic etiologies, neurological deficit caused by cervical spine, muscle strength lower than grade 4 in patients with pre-operative neurological deficit undergoing posterior spinal correction surgery.

Characteristics and clinical features of cauda equina syndrome: insights from a study on 256 patients

OBJECTIVE

To determine the frequency, clinical presentation, and etiological factors of cauda equina syndrome (CES).

MATERIALS AND METHOD

This retrospective study was done on 256 participants, and aimed to analyze the frequency and patterns of clinical presentation in suspected cases of CES. The inclusion criteria included participants aged 18 or older with medical records available for review and having red-flagged symptoms for CES. The study collected information on various factors such as age, gender, confirmation of CES on MRI, neurological deficits, etiological factors, duration of symptoms, and more. The data collected was analyzed using descriptive statistics and logistic regression to identify significant variables between MRI-proven CES and suspected CES.

RESULTS

The mean age was 58.05 ± 19.26 years, with 151 females (58.98%) and 105 males (41.02%). The majority (50.78%) had a neurological deficit, while other symptoms included difficulty initiating micturition or impaired sensation of urinary flow (17.58%), loss of sensation of rectal fullness (3.12%), urinary or faecal incontinence (35.16%), bilateral sciatica (21.88%), neurological symptoms in the lower limbs (25.00%), anaesthesia or any leg weakness (24.22%), and bilateral sciatica as the predominant symptom (21.88%). Symptoms were chronic in 47.27% and acute in 21.88%. The odds of MRI-proven CES increase by 3% per year of age. Neurological deficit was strongly associated with MRI-proven CES (OR = 14.97), while loss of sensation of rectal fullness increased the odds by 10-fold (OR = 10.62).

CONCLUSION

CES can present with various symptoms, including the bilateral neurological deficit, urinary and faecal incontinence, and bilateral sciatica, with age, severe bilateral neurological deficit, and loss of sensation of rectal fullness being associated with MRI-proven CES. Early diagnosis and treatment are crucial for better outcomes.

Cerebral blood flow velocity and oxygenation in neonatal aortic arch repair at two perfusion temperatures

OBJECTIVES

(i) To monitor cerebral blood flow velocity (CBFv) throughout aortic arch repair surgery and during the recovery period. (ii) To examine the relationship between transcranial doppler ultrasound (TCD) and near-infrared spectroscopy (NIRS) during cardiac surgery. (iii) To examine CBFv in patients cooled to 20°C and 25°C.

METHODS

During aortic arch repair and after surgery, measurements of TCD, NIRS, blood pH, pO2, pCO2, HCO3, lactate, Hb, haematocrit (%) and temperature (core and rectal) were recorded in 24 neonates. General linear mixed models were used to examine differences over time and between two cooling temperatures. Repeated measures correlations were used to determine the relationship between TCD and NIRS.

RESULTS

CBFv changed during arch repair (main effect of time: P = 0.001). During cooling, CBFv increased by 10.0 cm/s (5.97, 17.7) compared to normothermia (P = 0.019). Once recovering in paediatric intensive care unit (PICU), CBFv had increased from the preoperative measurement by 6.2 cm/s (0.21, 13.4; P = 0.045). CBFv changes were similar between patients cooled to 20°C and 25°C (main effect of temperature: P = 0.22). Repeated measures correlations (rmcorr) identified a statistically significant but weak positive correlation between CBFv and NIRS (r = 0.25, P≤0.001).

CONCLUSIONS

Our data suggested that CBFv changed throughout aortic arch repair and was higher during the cooling period. A weak relationship was found between NIRS and TCD. Overall, these findings could provide clinicians with information on how to optimise long-term cerebrovascular health.

Cervical spine fractures in ankylosing spondylitis patients: an analysis of the presentation and clinical results of 110 surgically managed patients in two spine centers

PURPOSE

In this work, a two-center study was performed to study the clinical presentation of cervical spine fractures in ankylosing spondylitis (AS) patients and assess the surgical management of these fractures.

METHODS

A retrospective analysis of prospectively collected data in two level-1 spine surgery centers was performed. Both spine centers have a standard database for all admitted patients. Inclusion criteria were surgically treated AS with cervical spine fracture diagnosis (from C1 to Th3) and postoperative follow-up minimum of 12 months.

RESULTS

One hundred ten patients (105 male/5 female) were included. The mean age was 62 ± 10 years. The mean time between trauma and surgery was 49 ± 42 days. There was a history of mild trauma in 72 patients (65.4%). The clinical presentation was a pain in all patients. Twenty-seven (24.6%) had a neurological deficit at admission. The most common fracture level was C6/7 in 63 patients (57.23%). The VAS was 7 ± 1, and NDI was 34 ± 8 in the preoperative assessment. The mean preoperative kyphosis angle was 48 ± 26° between C2 and C7. Positioning and preparing of the patients on the operation table took a mean of 57 ± 28 min. The surgical approach was dorsal in 59 patients (53.6%), combined in 45 patients (40.9%), and ventral in 6 patients (6,5%). The mean number of the fixed levels was 6 ± 2 levels. Intraoperative complications occurred in 9 patients (8.2%). Postoperative Cobb angle improved to a mean of 17 ± 9 degrees. Neurological improvement occurred in 20/27 patients. In 12 patients, the recovery was complete. The mean postoperative follow-up was 46 ± 18 months. VAS improved to 3 ± 1, and NDI improved to 14 ± 6 at the last postoperative visit. The improvement was clinically significant (p = 0.01 and 0.00, respectively).

CONCLUSION

High suspicion of cervical spine fractures is necessary for patients with AS. CT and MRI images are necessary to rule out cervical spine fractures in AS patients, especially to detect occult fractures. Surgical treatment is safe, and the posterior approach with long-segment fusion is the approach of choice in this group of patients.

Percutaneous versus open posterior stabilization and decompression in AOSpine-type A3 thoracolumbar fractures with neurological deficit

BACKGROUND

This retrospective cohort study aimed to compare the clinical and radiological outcomes between two treatment strategies focusing on non-osteoporotic AOSpine-type A3 fractures of the thoracolumbar spine with neurological deficits at levels T11 to L2.

METHODS

In total, 67 patients between 18 and 60 years of age who were treated operatively with either of the two treatment strategies were included. One treatment strategy included open posterior stabilization and decompression, whereas the other was based on percutaneous posterior stabilization and decompression via a tubular retraction system. Demographic data, surgical variables, and further parameters were assessed. Patient-reported outcomes (PROs), including the Visual Analog Scale (VAS), the Oswestry Disability Index (ODI), and the American Spinal Injury Association (ASIA) impairment score, were measured to assess functional outcomes. The regional Cobb angle (CA), the anterior height ratio of the fractured vertebrae (AHRV), and the degree of canal encroachment (DCE) were assessed. The ASIA score was used to assess neurological function recovery. The follow-up period was at least 12 months.

RESULTS

Surgical time and postoperative hospital stay were significantly shorter in the minimally invasive surgery (MIS) group. Intraoperative blood loss was significantly less in the MIS group. Regarding radiological outcome, CA and AHRV at the time of follow-up did not show a significant difference. DCE at the time of follow-up was significantly improved in the MIS group. Lower VAS scores and better ODIs were observed in the MIS group at the 6-month follow-up, but similar outcomes were observed at the 12-month follow-up. The ASIA score was similar between both groups at the 12-month follow-up.

CONCLUSIONS

Both treatment strategies are safe and effective; however, MIS could provide earlier pain relief and better functional outcomes compared with OS.

Intra-Operative Neurophysiological Monitoring in Patients with Thoracic Spinal Stenosis: Its Feasibility and High-Risk Factors for New Neurological Deficit

OBJECTIVE

Considering the high risk of postoperative neurological complications for patients with thoracic spinal stenosis (TSS), intra-operative neurophysiological monitoring (IONM) has been used for detecting possible iatrogenic injury timely. However, the IONM waveforms are often unreliable. This article is designed to determine the test performance of somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) during surgical thoracic decompression in patients with TSS, and to investigate the risk factors associated with deteriorated neurologic function at immediate postoperation.

METHODS

Patients undergoing posterior spinal fusion from February 2009 to December 2020 were retrospectively reviewed. Patients were divided into the deteriorated neurologic function (DNF) group and the improved/intact neurological function (INF) group based on the postoperative neurological status. Demographic parameters such as gender, age, height, weight, etiology and IONM data were compared between groups. Demographics and IONM data between DNF and INF groups were compared by independent t or nonparametric tests. The incidence of abnormal SEP was analyzed by Chi-square test.

RESULTS

A total of 108 patients (63 males, 45 females) with an average age of 53.5 ± 14.0 years were included. The SEP and MEP records were available in 94 and 98 patients, with the overall success rates being 87.0% and 90.7%, respectively. The sensibilities and specificities were 100% and 88.2% for SEP, 100% and 98.8% for MEP, respectively. There were 17 patients in DNF group and 91 patients in INF group. High weight (79.1 ± 14.6 vs 69.7 ± 15.7 kg, P = 0.024), high inter-side difference of MEP amplitude (899.1 ± 997.5 vs 492.3 ± 512.4 μV, P = 0.013) and high incidence of abnormal SEP (94.1% vs 64.8%, P = 0.024) were observed in the DNF group. Fourteen (82.4%) patients in the DNF group showed improvement in neurological status during follow-up.

CONCLUSIONS

The overall success rates were 87.0% for SEP and 90.7% for MEP in patients with TSS.

Impact of Long-Term Antithrombotic and Statin Therapy on the Clinical Outcome in Patients with Cavernous Malformations of the Central Nervous System: A Single-Center Case Series of 428 Patients

INTRODUCTION

Literature regarding the safety and efficacy of antithrombotic (antiplatelet or anticoagulant) therapy and statins in patients with cavernous malformations (CMs) of the central nervous system is sparse, resulting in uncertainty about its use in clinical practice. The aim of this study was to analyze the impact of antithrombotic therapy and statins on the risk of hemorrhage and focal neurological deficit in patients with CMs.

METHODS

The authors' institutional database was screened for all patients with CMs of the central nervous system treated at their institution between 2006 and 2018. Patients with radiological and/or histological diagnosis of CMs, clinical baseline characteristics, available patient's medication history, and follow-up data were included in this study. Time-to-event probability (hemorrhage or focal neurological deficit) as well as the number of events (hemorrhage or focal neurological deficit) during follow-up were assessed in patients who were categorized according to their medical treatment (antithrombotic therapy, statins, combined therapy, or no treatment).

RESULTS

Four hundred twenty-eight patients with CMs were eligible and included in the final analysis. Sixty-nine (16.1%) patients were on long-term antithrombotic therapy and 46 (10.6%) on long-term statins, of whom 31 patients were on a combination of both. The probability of experiencing first hemorrhage or focal neurological deficit was less likely in patients on antiplatelet therapy (HR 0.09, 95% CI 0.021-0.39, p = 0.001), anticoagulant therapy (HR 0.12, 95% CI 0.016-0.85, p = 0.034), or the combination thereof (HR 0.12, 95% CI 0.016-0.93, p = 0.043) compared to patients with no antithrombotic treatment. The number of hemorrhages and focal neurological deficits were significantly lower in patients on antithrombotic therapy compared to patients on no treatment during follow-up. In patients on statins alone, the time-to-event probability was comparable to that of patients on no treatment (HR 0.91, 95% CI 0.438-1.91, p = 0.812), and the number of events was similar to patients on no treatment.

CONCLUSION

The results of our study provide further evidence that antithrombotic therapy alone or in combination with statins in patients with CMs of the central nervous system does not increase the risk of hemorrhage or focal neurological deficit but, on the contrary, may have some benefit.

Analysis of the clinical characteristics and predisposing factors for neurological deficit with Hangman fractures

BACKGROUND

Hangman fracture is the second most common injury of the upper cervical spine, and neurological deficit with Hangman fracture is not rare. To our knowledge, few reports have statistically analyzed the predisposing factors for this injury. The objective of this study was to describe the clinical characteristics of neurological deficit associated with Hangman fracture and evaluate its risk factors.

METHODS

In this retrospective study, 97 patients with Hangman fractures were included. Data on the age, sex, injury etiology, neurological deficits, and associated injuries were obtained and evaluated. The pretreatment parameters, anterior translation and angulation of C2/3, presence of the posterior vertebral wall (PVW) fractures of C2, and presence of spinal cord signal changes were measured. Twenty-three patients with neurological deficits after Hangman fractures comprised group A, and 74 patients without neurological deficit comprised group B. Student's t-test or a nonparametric test and the chi-square test were used to evaluate the differences between groups. Binary logistic regression analysis was used to identify the risk factors for neurological deficit.

RESULTS

Among the 23 patients in group A, 2 were American Spinal Injury Association (ASIA) scale B, 6 were C, and 15 were D, and spinal cord magnetic resonance imaging signal change was observed at the level of C2-C3 disc, C2, or both. Patients with the combination of PVW fractures and ≥ 50% significant translation or angulation of C2/3 were significantly more likely to have a neurological deficit. Both factors remained significant in binary logistic regression analysis.

CONCLUSIONS

Neurological deficit after Hangman fractures always presents clinically as a partial neurological impairment. The combination of PVW fractures with ≥ 1.8 mm of translation or ≥ 5.5° of angulation of C2/3 was the predisposing factor for neurological deficit with Hangman fractures.

Intraoperative Optic Nerve Sheath Diameter as a Predictor of Early Tacrolimus Neurotoxicity after Living Donor Liver Transplantation

BACKGROUND

During liver transplantation, graft reperfusion triggers cerebral hyperemia, increases intracranial pressure, and disrupts the blood-brain barrier, thereby increasing the risk for immunosuppression neurotoxicity. Therefore, we tested the intraoperative optic nerve sheath diameter (ONSD) for predicting tacrolimus neurotoxicity after liver transplantation.

BASIC PROCEDURES

We prospectively included 100 adult patients who underwent living donor liver transplantation. The ultrasonographic ONSD 5 min after reperfusion was used as the index test, whereas the occurrence of early tacrolimus neurotoxicity was used as the reference. The area under the receiver operating characteristic curve (AUROC) was used to estimate the ONSD prediction accuracy. We reported the specificity and sensitivity of ONSD 5 and 30 min after reperfusion. Cutoffs were derived from the ROC curves. In addition, we used regression to control for confounders while testing the association between the ONSD and tacrolimus neurotoxicity.

MAIN FINDINGS

The AUROC at T3 was 0.74 (95% confidence interval (CI), 0.63-0.85, P < 0.001). An ONSD of ≥6.4 mm at T3 had an 86% sensitivity (95% CI, 68%-96%) and 53% specificity (95% CI, 41%-65%). An ONSD of ≥6.4 mm at T3 had an adjusted odds ratio for tacrolimus neurotoxicity of 6.3 (95% CI, 1.9-21, P = 0.003).

CONCLUSIONS

This data indicates that intraoperative ultrasonic ONSD after reperfusion can predict tacrolimus neurotoxicity after liver transplantation.

TRIAL REGISTRATION

NCT03799770; registered on January 1st, 2019.

Comparing carotid endarterectomies with or without shunting in symptomatic and asymptomatic patients

BACKGROUND

Recent research shows that placement of an intraluminal shunt during a carotid endarterectomy (CEA) can be associated with postoperative complications. Therefore, we compared CEA operations with or without shunting to further analyze their clinical outcomes.

METHODS

From the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,736 cases between 2016 and 2019 were analyzed to compare adult symptomatic and asymptomatic carotid stenosis patients who underwent a CEA operation, with or without shunt placement.

RESULTS

Rates of stroke with a neurological deficit (p = 0.012), myocardial infarction (p = 0.021), and urinary tract infection (p = 0.030) were higher among symptomatic patients with shunting. Multivariate logistic regression revealed that risk of CNI was higher among both symptomatic (93.63%, p < 0.001) and asymptomatic (69.58%, p = 0.001) patients with shunting, irrespective of confounding variables.

CONCLUSION

Shunting was found to be associated with higher rates of postoperative complications in both symptomatic and asymptomatic patient populations.

The Role of Riluzole in Acute Traumatic Cervical Spinal Cord Injury with Incomplete Neurological Deficit: A Prospective, Randomised Controlled Study

Introduction

Riluzole, a benzothiazole sodium channel blocker is acknowledged as a neuroprotective agent in spinal cord injury (SCI). Most of this evidence is based on pre-clinical studies and its effectiveness in clinical setting is undetermined, heretofore.

Methods

A prospective, randomised-controlled study was conducted between April 2019 and March 2020 at a tertiary-level centre. Patients aged 18-65 years with sub-axial cervical spine injury, who presented within 72 h of injury with incomplete neuro-deficit, were included. They were randomised into groups A (riluzole was administered) and B (no adjuvants). All patients were followed up at 6 weeks/3/6/12 months, and clinical [ASIA motor/sensory scores/grade, SCIM3, and NRS (neuropathic pain)] and radiological evaluation was performed.

Results

Twenty-three and 20 patients were included in groups A and B. Two in group A were females, while others were males (p = 0.49). Mean age in groups A and B was 47.7 ± 14.8 and 51.2 ± 14.1 years (p = 0.44). Five patients died prior to 6th-week follow-up. Among the others, there was significant improvement in all neurological parameters in both groups (post-injury vs 1-year; motor score: p < 0.001, sensory score: p < 0.001, SCIM3: p < 0.001, NRS: p < 0.001). In both groups, initial significant improvement was noticed even at the 6th-week follow-up, which further continued until the end of 1 year. There was no statistically significant difference between groups A and B with respect to these neurological parameters (motor: p = 0.15, sensory: p = 0.39, SCIM3: p = 0.68, NRS: p = 0.06).

Conclusion

Administration of riluzole did not significantly improve neurological outcome/neuropathic pain in our cohort. Nevertheless, both our groups demonstrated an overall improvement in neurological outcome at 1 year, as compared with immediate post-injury status.

Treatment of high-grade brain arteriovenous malformations using a hybrid operating room: A prospective single-arm study

BACKGROUND

Optimal treatment of patients with high Spetzler-Martin (S-M) grade brain arteriovenous malformations (BAVMs) remains controversial. Few studies have investigated outcomes in such patients treated in a hybrid operating room (hOR).

OBJECTIVE

To examine outcomes of one-stop hybrid BAVM treatment in patients with high-grade lesions.

METHODS

We prospectively enrolled patients with high-grade BAVMs (S-M grade ≥3) aged 18-65 years who underwent one-stop hybrid BAVM treatment at our hospital between October 2016 and March 2021. High-grade BAVM patients who underwent surgery from 2010 to 2016 served as historical controls.

RESULTS

Forty-one high-grade BAVM patients underwent one-stop hybrid treatment in a hOR. Sixty-one propensity score-matched patients comprised the historical control group. The groups did not significantly differ in patient and BAVM characteristics. Intraoperative angiography in four patients of the hOR group demonstrated residual nidus that required further immediate resection. Main procedural complications included hemorrhage, neurologic deficit, and seizure. In the historical control group, diffuse angioarchitecture and arteriovenous fistula were independent risk factors for incomplete resection.

CONCLUSIONS

One-stop hybrid BAVM treatment is safe and effective for removal of high-grade BAVMs, especially those with diffuse or complex angioarchitecture. Preoperative embolization can effectively reduce blood flow while preserving motor and language function. The combined application of functional magnetic resonance imaging, electrophysiological monitoring, and awake craniotomy can successfully avoid causing neurological injury.

Continence management in children with severe caudal regression syndrome: role of multidisciplinary team and long-term follow-up

PURPOSE

Caudal regression syndrome (CRS) is a rare congenital abnormality including orthopedic deformities, urological, anorectal, and cardiac malformations. The clinical spectrum of CRS varies in severity, therefore multiple surgeries and complex medical care may be required with the efforts and support of a multidisciplinary team to ensure the most accurate treatment and the best outcome. The aim of our retrospective study was to evaluate the role of a multidisciplinary treatment and the long-term outcome in patients with severe CRS.

METHODS

Clinical, surgical and psychological data were collected for all patients with diagnosis of CRS, treated at our Pediatric Hospital from January 1995 to December 2020. Patients with a severe form of CRS according to Pang's classification were included in the study. All patients have been followed by a multidisciplinary team composed by urologists, neurosurgeons, neonatal and digestive surgeons, orthopedic surgeon, physiatrists and psychologists. On admission, patients were screened for CRS with sacrum, spine and legs X-ray, spine MRI, renal ultrasound, voiding cystography and urodynamic, and renography. Clinical data about bowel function were evaluated.

RESULTS

During the study period, 55 patients with CRS were treated at our Institution. Six out of 55 (10.9%), presented with severe form of CRS (5 pts with type 1; 1 pt, with type 2) and represent our study group. Diagnosis of severe CRS was made at birth because of the typical deformities of the pelvis (fusion of the iliac wings), and of the lower extremities (undeveloped legs with flexion of the knees, clubfoot). All patients presented with neurogenic bladder, 4/6 (66.6%) with vesicoureteral reflux (VUR) and 2/6 (33.3%) with renal agenesia and contralateral ectopic hypoplastic kidney. Bowel symptoms occurred in 5/6 pts (83.3%). All patients were started with an earlier clean intermittent catheterization (CIC) regimen. In 3 patients oxybutynin has been effective or well tolerated, while in other 3 onabotulinumtoxin A has been used. Vesicoureteral reimplantation has been performed in 1 patient, 2 required endoscopic treatment of VUR. On long-term, 2 patients required bladder augmentation with ileum and appendicostomy (Mitrofanoff). Low adherences in CIC have been observed in three patients, mainly at puberty. Two patients presented with chronic renal failure. One patient reported suicide proposal. Regarding social life, only one is regularly performing sport activity.

CONCLUSION

CRS is characterized by maldevelopment of the caudal half of the body with variable involvement of the gastrointestinal, genitourinary, skeletal, and nervous systems. Management of CRS includes a wide variety of interventions to address the full spectrum of possible anatomical abnormalities. Hence, a multidisciplinary team is also mandatory for a correct bladder and bowel management, in order to maintain continence and preserve renal function, improve quality of life and increase self-esteem.

Correlation analysis between D-dimer-to-fibrinogen-ratio and carotid plaque in young patients aged 18-45 with acute cerebral infarction

BACKGROUND

D-Dimer and fibrinogen were commonly used to detect the coagulation and fibrinolytic function, but D-dimer to fibrinogen ratio (DFR) in carotid plaque in young patients aged 18-45 with acute cerebral infarction (ACI) has not been used clinically. In this work, we focused on the evaluation of the DFR value of this group of patients and analyzed its possible correlation.

METHODS

A total of 164 patients with ACI patients aged 18-45 were selected as research subjects after their first admission. They had undergone carotid plaque contrast-enhanced ultrasound (CEUS) and were divided into two groups with carotid plaque (n = 97) and with no carotid plaque (n = 67). According to NIHSS score and carotid plaque grade, the clinical symptoms of patients were judged. Univariate and multivariate analyses were conducted to compare the risk factors of carotid plaque in ACI patients.

RESULTS

The DFR value of patients in the carotid plaque group (103.41 ± 20.81) was significantly higher than that of the no carotid plaque control group (88.9 ± 26.51). We also identified DFR X10³ was the only independent risk factor (β = 0.53; 95% CI, 0.914-0.984; P = 0.05). DFR X10³ was increased with the severity of the disorder and with the CEUS grades. The area under the DFR curve was 0.673 (95% CI 0.584～0.762).

CONCLUSION

The value of the DFR is positively correlated with CEUS carotid plaque grading and NIHSS score, which can predict the severity of carotid plaque in ACI patients aged 18-45. Therefore it is worthy of clinical application.

Outcomes of 53 thoracic outlet syndrome cases with confirmed neurological deficit

INTRODUCTION

Neurogenic thoracic outlet syndromes (TOS) are dominated by the nonspecific forms. This study focuses only on the rarer true forms related to proximal nerve compression in the thoracic outlet, with the presence of motor (atrophy of the hand's intrinsic muscles) and/or sensory (hypoesthesia in the territory of the medial antebrachial cutaneous nerve) deficits. The objectives of this study were to define the clinical characteristics, anatomical causes and surgical results of this condition.

PATIENTS AND METHODS

Single-center retrospective study of 53 consecutive cases in 50 patients with an objective clinical deficit confirmed by nerve conduction studies. The population consisted of 47 adults and 3 children, 9 males and 41 females, with a mean age of 39 years (9-80 years), diagnosed between July 1994 and December 2019. An objective motor deficit was present in 50 cases, with the remaining 3 having a sensory deficit only. Forty cases underwent surgery, most often via the supraclavicular approach, while 13 cases did not undergo surgery because their deficit was longstanding and non-progressive.

RESULTS

One operated patient was lost in follow-up. An analysis of the medical records of 18 cases, including 15 operated cases found complete recovery in 4 cases, significant improvement in 9 cases and small improvement in 2 cases at a mean follow-up of 53 months (1-162 months). Thirty-four cases were reviewed in person, including 24 operated cases and evaluated with a mean follow-up of 135 months (36-284 months): the pain had disappeared in 21 cases, thenar atrophy persisted in 17 cases, which was associated with a claw-hand deformity in 3 cases, while 2 cases had an isolated claw-hand deformity. The patients were very satisfied with the procedure in 15 cases and satisfied in 9 cases. They evaluated the benefit of surgery at 87% and their upper limb function increased from 38% (10-60%) preoperatively to 77% (60-100%) at the review.

CONCLUSION

Few studies in the literature have focused on true neurogenic TOS cases. The treatment is surgical in progressive cases; an anatomical anomaly is always present. Surgical treatment eliminates the pain and helps to stabilize or even partially resolve the deficit. Despite a moderate objective gain, the patients' feeling of functional improvement is important with a high satisfaction rate.

LEVEL OF EVIDENCE

IV, retrospective.

Sudden vision loss and neurological deficits after facial hyaluronic acid filler injection

BACKGROUND

The ongoing expansion of the cosmetic armamentarium of facial rejuvenation fails to uncover the inherent risks of cosmetic interventions. Informed consent to all risks of cosmetic filler injections and potential sequelae, including ocular and neurological complications, should be carefully ensured. We present two cases of complications following facial hyaluronic acid filler injections.

CASE PRESENTATIONS

Case 1: A 43-year-old woman presented with monocular vision loss of the left eye, associated ptosis, ophthalmoplegia, periocular pain and nausea, cutaneous changes of the glabella region and forehead, and sensory impairment in the left maxillary branch dermatome (V2) after receiving a hyaluronic acid (HA) filler injection into the left glabellar area. On ophthalmological examination, an ophthalmic artery occlusion (OAO) was diagnosed upon identification of a "cherry-red spot". Magnetic resonance imaging (MRI) revealed a left ischemic optic neuropathy. Supportive therapy and hyaluronidase injections were initiated. A follow-up MRI of the head performed two months after presentation corresponded to stable MRI findings. The patient had irreversible and complete vision loss of the left eye, however, the ptosis resolved. Case 2: A 29-year-old woman was admitted to hospital a few hours after a rhinoplasty and cheek augmentation with hyaluronic acid, presenting with acute monocular vision loss in the right eye, retrobulbar pain, fatigue and vomiting. In addition, the patient presented a harbinger of impending skin necrosis and a complete oculomotor nerve palsy on the right side, choroidal ischemia and vision impairment. Supportive treatment and hyaluronidase injections into the ischemic tissue were initiated. A small scar at the tip of the nose, vision impairment and an irregular pupillary margin on the right side persisted at follow-up.

CONCLUSION

These two case reports and the literature review emphasize the pathophysiological mechanisms leading to potentially devastating complications. In order to reduce the risk of vision loss secondary to cosmetic filler injections, practitioners should possess a thorough knowledge of anatomy and preventive strategies.

Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery

PURPOSE

To establish expert consensus on various parameters that constitute elevated risk during spinal deformity surgery and potential preventative strategies that may minimize the risk of intraoperative neuromonitoring (IONM) events and postoperative neurological deficits.

METHODS

Through a series of surveys and a final virtual consensus meeting, the Delphi method was utilized to establish consensus among a group of expert spinal deformity surgeons. During iterative rounds of voting, participants were asked to express their agreement (strongly agree, agree, disagree, strongly disagree) to include items in a final set of guidelines. Consensus was defined as ≥ 80% agreement among participants. Near-consensus was ≥ 60% but < 80% agreement, equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%.

RESULTS

Fifteen of the 15 (100%) invited expert spinal deformity surgeons agreed to participate. There was consensus to include 22 determinants of high-risk (8 patient factors, 8 curve and spinal cord factors, and 6 surgical factors) and 21 preventative strategies (4 preoperative, 14 intraoperative, and 3 postoperative) in the final set of best practice guidelines.

CONCLUSION

A resource highlighting several salient clinical factors found in high-risk spinal deformity patients as well as strategies to prevent neurological events was successfully created through expert consensus. This is intended to serve as a reference for surgeons and other clinicians involved in the care of spinal deformity patients.

LEVEL OF EVIDENCE

Level V.

Development of consensus-based best practice guidelines for response to intraoperative neuromonitoring events in high-risk spinal deformity surgery

PURPOSE

To expand on previously described intraoperative aids by developing consensus-based best practice guidelines to optimize the approach to intraoperative neuromonitoring (IONM) events associated with "high-risk" spinal deformity surgery.

METHODS

Consensus was established among a group of experienced spinal deformity surgeons by way of the Delphi method. Through a series of iterative surveys and a final virtual consensus meeting, participants expressed their agreement (strongly agree, agree, disagree, and strongly disagree) with various items. Consensus was defined as ≥ 80% agreement ("strongly agree" or "agree"). Near-consensus was defined as ≥ 60% but < 80%. Equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%.

RESULTS

15 out of 15 (100%) invited surgeons agreed to participate. Final consensus supported inclusion of 105 items (53 in Response Algorithm, 13 in Ongoing Consideration of Etiology, 31 in Real-Time Data Scenarios, 8 in Patterns of IONM Loss), which were organized into a final set of best practice guidelines.

CONCLUSION

Detailed consensus-based best practice guidelines and aids were successfully created with the intention to help organize and direct the surgical team in exploring and responding to neurological complications during high-risk spinal deformity surgery.

LEVEL OF EVIDENCE

Level V.

[Effect of moxibustion on Nogo/neurotrophin receptor signaling pathway in rats with cerebral ischemia/reperfusion injury]

OBJECTIVE

To observe the effect of moxibustion treatment on the expression of Nogo-A, Nogo receptor (NgR), neurotrophin receptor p75 (p75NTR) and leucine rich repeat and Ig domain containing 1 (Lingo-1) in brain tissue of rats with cerebral ischemia/reperfusion injury (CI/RI), so as to analyze its mechanism underlying improvement of CI/RI.

METHODS

Male SD rats were randomly divided into sham operation group (16 rats), model group (17 rats), NEP1-40 (extracellular peptide residues 1-40, a blocker targeting NgR) group (model+blocker, 17 rats) and moxibustion group (model+moxibustion, 17 rats). The CI/RI model was established by occlusion of the left middle cerebral artery (MCAO). Moxibustion was applied to "Baihui"(GV20), right "Quchi"(LI11) and "Zusanli"(ST36) for 20 min, once a day for 14 days, with 2 days' rest after the top 7 days' intervention. For rats of the NEP1-40 group, 30 μL PBS containing 18 μg NEP 1-40 was injected into the epidural inferior vena (L5-S1) via a polyvinyl chloride conduit. The neurological deficit state in each group was evaluated by Longa's 5-point scale and Feeney's 7-point scale of beam walking test (BWT). The cerebral infarct volume was assessed by 2,3,5-triphenyltetrazole chloride staining. The brain tissue between the central anterior and posterior sulcus was taken for observing the expression of NgR and Lingo-1 by fluorescence double-label method, and for determining the expression levels of Nogo-A, NgR, p75NTR and Lingo-1 mRNAs and proteins by real-time quantitative PCR and Western blot, respectively.

RESULTS

After modeling, the Longa's score, infarct volu-me percent, expression levels of Nogo-A, NgR, Lingo-1 and p75NTR mRNAs and proteins were significantly increased (P<0.01) and BWT score was obviously decreased (P<0.01) in the model group relevant to the sham operation group. In comparison with the model group, the increase of Longa's score, infarct volume percentage, expression levels of Nogo-A, NgR, Lingo-1 and p75NTR mRNAs and proteins and decrease of BWT score in NEP1-40 and moxibustion groups were reversed (P<0.01) except Nogo-A protein in the NEP1-40 group. The effect of moxibustion was significantly superior to that of blocker NEP1-40 in redu-cing the infarct volume percentage, and down-regulating the expression of Nogo-A mRNA and protein, p75NTR mRNA and protein, NgR and Lingo-1 proteins (P<0.01, P<0.05).

CONCLUSION

Moxibustion, similar to blocker NEP1-40 of NgR, can improve neurological dysfunction in CI/RI rats, which may be related to its functions in reducing cerebral infarction and down-regulating the activity of Nogo/neurotrophin receptor signaling pathway.

Acute ischemic stroke after first dose of inactivated COVID-19 vaccine: A case report

The acute cerebral ischemia induced by the COVID-19 vaccine is one of the side effects. We report the first case of a patient who suffered from a neurological deficit mimicking a stroke after receiving his 1st dose of the inactivated COVID-19 vaccine BIBP (Sinopharm) and who mainly developed cerebral venous thrombosis. Our reported case is a 36-year-old man who was admitted to our intensive care unit 2 days after his first injection dose of the inactivated COVID-19 vaccine BIBP (Sinopharm). He presented a numbness in his left arm and legs with headaches 24 hours after the vaccine injection. In the second day, he had asymmetry of the face which was aggravated by the installation of disturbance of consciousness and a state of agitation. His vital signs were normal. A brain CT scan without injection was done showing a right deep parietal ischemic stroke. The treatment was initiated by aspirin. cerebral MRI showed a very extensive stroke ischemic in the superficial and deep right parietal territory with the onset of hemorrhagic rearrangement of the right basal ganglia, magnetic resonance imaging angiography of the supra-aortic trunks was normal. The patient gradually improved and was discharged after 15 days of his stay in the intensive care unit. The installation of ischemic stroke reported in our young patient after receiving his first dose of inactivated COVID-19 vaccine BIBP; could be a new immune response to the vaccine.

Indications for Nonsurgical Treatment of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar spine is the most injured spinal region in blunt trauma. Literature on the indications for nonoperative treatment of thoracolumbar fractures is conflicting. The purpose of this systematic review is to clarify the indications for nonsurgical treatment of thoracolumbar fractures. We conducted a systematic literature search between 2010 to 2020 on PubMed/MEDLINE, and Cochrane Central. Up-to-date literature on the indications for nonoperative treatment of thoracolumbar fractures was reviewed to reach an agreement in a consensus meeting of WFNS (World Federation of Neurosurgical Societies) Spine Committee. The statements were voted and reached a positive or negative consensus using the Delphi method. For all of the questions discussed, the literature search yielded 1,264 studies, from which 54 articles were selected for full-text review. Nine studies (4 trials, and 5 retrospective) evaluating 759 participants with thoracolumbar fractures who underwent nonoperative/surgery were included. Although, compression type and stable burst fractures can be managed conservatively, if there is major vertebral body damage, kyphotic angulation, neurological deficit, spinal canal compromise, surgery may be indicated. AO type B, C fractures are preferably treated surgically. Future research is necessary to tackle the relative paucity of evidence pertaining to patients with thoracolumbar fractures.

The prognosis and recovery of major postoperative neurological deficits after corrective surgery for scoliosis : an analysis of 65 cases at a single institution

AIMS

The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years.

METHODS

A major neurological deficit was identified in 65 of 8,870 patients who underwent corrective surgery for scoliosis, including eight with complete paraplegia and 57 with incomplete paraplegia. There were 23 male and 42 female patients. Their mean age was 25.0 years (SD 16.3). The aetiology of the scoliosis was idiopathic (n = 6), congenital (n = 23), neuromuscular (n = 11), neurofibromatosis type 1 (n = 6), and others (n = 19). Neurological function was determined by the American Spinal Injury Association (ASIA) impairment scale at a mean follow-up of 45.4 months (SD 17.2). the patients were divided into those with recovery and those with no recovery according to the ASIA scale during follow-up.

RESULTS

The incidence of major deficit was 0.73%. At six-month follow-up, 39 patients (60%) had complete recovery and ten (15.4%) had incomplete recovery; these percentages improved to 70.8% (46) and 16.9% (11) at follow-up of two years, respectively. Eight patients showed no recovery at the final follow-up. The cause of injury was mechanical in 39 patients and ischaemic in five. For 11 patients with misplaced implants and haematoma formation, nine had complete recovery. Fisher's exact test showed a significant difference in the aetiology of the scoliosis (p = 0.007) and preoperative deficit (p = 0.016) between the recovery and non-recovery groups. A preoperative deficit was found to be significantly associated with non-recovery (odds ratio 8.5 (95% confidence interval 1.676 to 43.109); p = 0.010) in a multivariate regression model.

CONCLUSION

For patients with scoliosis who develop a major neurological deficit after corrective surgery, recovery (complete and incomplete) can be expected in 87.7%. The first three to six months is the time window for recovery. In patients with misplaced implants and haematoma formation, the prognosis is satisfactory with appropriate early intervention. Patients with a preoperative neurological deficit are at a significant risk of having a permanent deficit. Cite this article: Bone Joint J 2022;104-B(1):103-111.

Preclinical evaluation of circadian rhythm in ischemic stroke outcomes

Stroke is a leading cause of disability and death worldwide. There is evidence that there is a circadian rhythm in stroke with peak occurrence in the morning (6 to 10 am). However, it is not clear if the size of infarcts and the outcome of stroke also varies during the 24-hour period. We hypothesized that the size of cerebral infarct and outcome from stroke would show circadian variation in a mouse suture occlusion model. Seven to eight-month-old C57BL/6J (n =10-12 mice/group) mice were randomly assigned to undergo middle cerebral artery occlusion (MCAO) for 60 minutes at different time points during the 24h day following zeitgeber time at ZT0, ZT6, ZT12, and Z18. Cerebral blood flow was monitored by Laser Speckle Contrast Imaging at baseline after occlusion, and again at 24h post-occlusion. Neurological deficit was observed by using Bederson score at 24h and 48h. The corner test was used to detect unilateral abnormalities in sensory and motor functions in the stroke mice at 48h. To estimate brain infarction, 2,3,5-tryphenyltetrazolium chloride staining was performed 48h after stroke and the infarct area was quantified using NIH-Image J software. We did not find a significant difference in cerebral blood flow at any time point. There was a significant decrease in neurological deficit as assessed using the Bederson Score from 24h (1.82 ± 1.11) to 48h (1.10 ± 0.12) in the ZT18 (midnight) period (p = 0.0025), however there were no differences between groups at 48h. In the corner test, we found right turn preference significantly higher (p = 0.0348) at noon/ZT06 (9.5 ± 1.06) compared to the fully awake (5.5 ± 4.06) (midnight, ZT18) period and ZT0 (6 am, 4.8 ± 0.97, p = 0.0087). Similarly, the infarction volume was significantly higher (p = 0.0220) during the sleep (ZT06, noon) period (35.22 ± 20.77) than when the ischemic mice were fully awake during the midnight/ZT18 period (15.68 ± 7.54). This is the first report demonstrating that mice have larger infarcts and worse short-term outcomes during their sleep period (noon/ZT06) than during their awake period (midnight/ZT18).

Omi inhibition ameliorates neuron apoptosis and neurological deficit after subarachnoid hemorrhage in rats

Background

Subarachnoid hemorrhage (SAH) is a severe neurological emergency, resulting in cognitive impairments and threatening human's health. Currently, SAH has no effective treatment. It is urgent to search for an effective therapy for SAH.

Objective

To explore the expression of Omi protein after subarachnoid hemorrhage in rats.

Methods

SAH rat model was established by injecting blood into the prechiasmatic cistern. Neurological deficit was assessed by detecting neurological deficit scores and brain tissue water contents. Apoptotic cells were evaluated by TUNEL staining and IHC staining. Omi and Cleaved caspase 3 expressions in nerve cells were determined by double staining using IF. Apoptosis-related proteins were measured by Western blotting assay.

Results

SAH rat model was successfully established, showing more apoptotic cells and high neurological deficit scores in SAH rat. In SAH rat model, Omi expression in nerve cells was elevated and the upregulation of Omi mainly occurred in cytoplasm, accompanied by the degradation of XIAP and the increased cleaved caspase 3/9 and cleaved PARP. Once treated with UCF-101, a specific inhibitor of Omi, the increased cell apoptosis, left/right brain moisture contents and neurological deficits were notably reversed in SAH rat brain. Of note, SAH-induced the increases of apoptosis-related protein in nerve cells were also rescued by the administration of UCF-101.

Conclusions

UCF-101-mediated Omi inhibition decreased the degradation of XIAP and subsequently inhibited the activation of apoptosis-related proteins, decreased nerve cell apoptosis, leading to the improvement on early brain injury in SAH rat. UCF-101-based Omi inhibition may be used to treat SAH with great potential application.

Laser interstitial thermal therapy for newly diagnosed glioblastoma

Gliomas are the most frequent primary brain tumor in adults. Patients with glioblastoma (GBM) tumors deemed inoperable with open surgical techniques and treated only with chemo/radiation have a median overall survival of less than 9 months. Laser interstitial thermal therapy (LITT) has emerged as a cytoreductive alternative to surgery for these patients. The present study describes the outcomes of twenty patients with newly diagnosed, IDH wild-type glioblastoma treated with LITT. We retrospectively reviewed patients with newly diagnosed, unresectable GBM who underwent LITT at our institution. Progression-free survival (PFS) was the primary endpoint measured in our study, defined as time from LITT to disease progression. Results Twenty patients were identified with newly diagnosed, inoperable GBM lesions who underwent LITT. The overall median PFS was 4 months (95% CI = 2 - N/A, upper limit not reached). The median progression-free survival (PFS) for patients with less than 1 cm 3 residual tumor (gross total ablation, GTA) was 7 months (95% CI = 6 - N/A, upper limit not reached), compared to 2 months (95% CI = 1 - upper limit not reached) for patients with a lower GTA (p = .0019). The median overall survival was 11 months (95% CI = 6 - upper limit not reached). Preoperative Karnofsky performance score (KPS) less than or equal to 80 and deep-seated tumor location were significantly associated with decreased PFS (HR, .18, p = .03; HR, .08, p = .03, respectively). At the end of 1 month, only 4 patients (20%) experienced persistent motor deficits. LITT is a safe and effective treatment for patients with unresectable, untreated GBM with rates of survival and local recurrence comparable to patients with surgically accessible lesions treated with conventional resection. Careful patient selection is needed to determine if GTA is attainable.

Acute prolonged motor aura resembling ischemic stroke after COVID - 19 vaccination (CoronaVac): the first case report

Background

We report the first case of a patient who suffered transient focal neurological deficit mimicking stroke following CoronaVac vaccination. However, instead of an ischemic stroke, motor aura was suspected.

Case presentations

A 24 year-old Thai female presented with left hemiparesis fifteen minutes after receiving CoronaVac. She also had numbness of her left arm and legs, flashing lights, and headaches. On physical examination, her BMI was 32.8. Her vital signs were normal. She had moderate left hemiparesis (MRC grade III), numbness on her left face, arms, and legs. Her weakness continued for 5 days. A brain CT scan was done showing no evidence of acute infarction. Acute treatment with aspirin was given. MRI in conjunction with MRA was performed in which no restricted diffusion was seen. A SPECT was performed to evaluate the function of the brain showing significant hypoperfusion of the right hemisphere. The patient gradually improved and was discharged.

Discussions

In this study, we present the first case of stroke mimic after CoronaVac vaccination. After negative imaging studies had been performed repeatedly, we reach a conclusion that stroke is unlikely to be the cause. Presumably, this phenomenon could possibly have abnormal functional imaging study. Therefore, we believed that it might be due to cortical spreading depression, like migraine aura, which we had conducted a literature review.

Management of degenerative spondylolisthesis: development of appropriate use criteria

BACKGROUND CONTEXT

Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized.

PURPOSE

The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process was used.

METHODS

The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory.

RESULTS

There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

SUMO1 Deficiency Exacerbates Neurological and Cardiac Dysfunction after Intracerebral Hemorrhage in Aged Mice

Small ubiquitin-like modifier 1 (SUMO1) reduces cardiac hypertrophy and induces neuroprotective effects. Previous studies have found that intracerebral hemorrhage (ICH) provokes cardiac deficit in the absence of primary cardiac diseases in mice. In this study, we tested the hypothesis that SUMO1 deficiency leads to worse brain and heart dysfunction after ICH and SUMO1 plays a key role in regulating brain-heart interaction after ICH in aged mice. Aged (18-20 months) female SUMO1 null (SUMO1-/-) mice and wild-type (WT) C57BL/6 J mice were randomly divided into four groups (n = 8/group): (1) WT-sham group, (2) SUMO1-/--sham group, (3) WT-ICH group, and (4) SUMO1-/--ICH group. Cardiac function was measured by echocardiography. Neurological and cognitive functional tests were performed. Mice were sacrificed at 10 days after ICH for histological and immunohistochemically staining. Compared with WT-sham mice, WT-ICH mice exhibited (1) significantly (P < 0.05) decreased SUMO1 expression in heart tissue, (2) evident neurological and cognitive dysfunction as well as brain white matter deficits, (3) significantly increased cardiac dysfunction, and (4) inflammatory factor expression in the heart and brain. Compared with WT-ICH mice, SUMO1-/--ICH mice exhibited significantly increased: (1) brain hemorrhage volume, worse neurological and cognitive deficits, and increased white matter deficits; (2) cardiac dysfunction and cardiac fibrosis; (3) inflammatory response both in heart and brain tissue. Aged SUMO1-deficient female mice subjected to ICH not only exhibit increased neurological and cognitive functional deficit but also significantly increased cardiac dysfunction and inflammatory cell infiltration into the heart and brain. These data suggest that SUMO1 plays an important role in brain-heart interaction.

SRC-3 Deficiency Exacerbates Neurological Deficits in a Mouse Model of Intracerebral Hemorrhage: Role of Oxidative Stress

Intracerebral hemorrhage (ICH) causes long term neurological abnormality or death. Oxidative stress is closely involved in ICH mediated brain damage. Steroid receptor cofactor 3 (SRC-3), a p160 family member, is widely expressed in the brain and regulates transactivation of Nrf2, a key component of antioxidant response. Our study aims to test if SRC-3 is implicated in ICH mediated brain injury. We first examined levels of SRC-3 and oxidative stress in the brain of mice following ICH and analyzed their correlation. Then ICH was induced in wild type (WT) and SRC-3 knock out mice and how SRC-3 deletion affected ICH induced brain damage, oxidative stress and behavioral outcome was assessed. We found that SRC-3 mRNA and protein expression levels were reduced gradually after ICH induction in WT mice along with an increase in oxidative stress levels. Correlation analysis revealed that SRC-3 mRNA levels negatively correlated with oxidative stress. Deletion of SRC-3 further increased ICH induced brain edema, neurological deficit score and oxidative stress and exacerbated ICH induced behavioral abnormality including motor dysfunction and cognitive impairment. Our findings suggest that SRC-3 is involved in ICH induced brain injury, probably through modulation of oxidative stress.

Contrast-induced encephalopathy and permanent neurological deficit: A case report and literature review

Background:

Contrast-induced encephalopathy (CIE) is a rare condition that occurs after intravenous or intra-arterial contrast agent administration. Patients generally show different ranges of neurological deficits, which generally resolve themselves spontaneously within 24–48 h or in rare cases within 2 weeks.

Case Description:

We report a case of CIE in a 54-year-old woman during retreatment for recanalization of communicating anterior artery aneurysm and with no history of allergic reaction to contrast agent. After the procedure, the patient developed right hemiplegia and complete aphasia; an MRI performed at 6 days excluded any signs of new ischemia and revealed a hyperintense signal on FLAIR sequences in the left cortical precentral gyrus corresponding to a hyperintense signal on DWI, suggesting a vasogenic edema. After 6 months, she clinically improved even if her previous neurological status was never restored while radiological findings did not change.

Conclusion:

According to the literature, many risk factors may play a role in the pathogenesis of CIE: we hypothesized that, among all of them, chronic hypertension and previous cerebral ischemic lesions were the most important in our case. Further studies are necessary to find the correlation between possible risk factors and neurotoxicity.

Surgery for cerebral cavernous malformations: a systematic review and meta-analysis

BACKGROUND

We sought to quantify the risks of neurosurgical excision of cerebral cavernous malformations (CCMs) in a systematic review of cohort studies.

METHODS

We updated our previous systematic review by searching OVID Medline, OVID EMBASE, and the Cochrane Library from 1 January 2013 to 30 April 2019. The primary outcome was a composite of death attributed to CCM or surgery, non-fatal symptomatic intracerebral haemorrhage (ICH), or new or worsened persistent non-haemorrhagic focal neurological deficit (FND).

RESULTS

We included 70 cohorts, 67 reporting surgery alone, and three compared surgery to conservative management. A total of 5,089 patients (median age 36 years, 52% female) underwent surgery (total follow-up 19,404 patient-years). The annual rate of the composite outcome was 4.2% (95% CI 2.9 to 5.7; 46 cohorts; I² = 93%), which was higher in cohorts reporting exclusively brainstem CCM (6.0%, 95% CI 4.1-8.3; 25 cohorts, I² = 92%) versus predominantly supratentorial CCM (2.4%, 95% CI 1.3-3.8, 21 cohorts, I² = 86%, p_het = 0.001). The annual rate of the composite outcome was higher in cohorts with > 95% presenting with ICH (6.1%, 95% CI 4.2-8.4; 23 cohorts, I² = 93%) versus others (2.3%, 95% CI 1.2-3.7; 23 cohorts, I² = 83%, p_het = 0.001). The incidence of the composite outcome did not change over time in cohorts of exclusively brainstem CCM (p = 0.7) or predominantly supratentorial CCM (p = 0.5).

CONCLUSIONS

The risk of death, ICH, or FND after CCM excision is ~ 4%. This risk is higher for brainstem CCM and CCM that have caused ICH but has not changed over time.

TRIAL REGISTRATION

This systematic review was registered (PROSPERO CRD42019131246).

Discoveries of the specific expression of lncRNAs and mRNAs in hippocampus of rats after traumatic brain injury

Objects

Explore the relationship between the neural function deficit and the changes of lncRNA and mRNA in hippocampus after traumatic brain injury (TBI) in rats.

Methods

Twenty male rats weighted 200-240 grams were randomly divided into sham group and TBI group. Neurologic severity score (NSS) was performed after operation, and the hippocampus of rats was collected for long non-coding RNAs (lncRNAs), mRNAs microarray detection, real-time quantitative PCR Detecting System (Q-PCR), western blot (WB) detection, and serum biochemical detection.

Results

The NSS score of the TBI group was significantly higher than the sham group. Compared with the sham group, 270 lncRNAs changed in the TBI group, of which 224 were up-regulated and 46 were down-regulated. Among up-regulated lncRNAs, mRNAs were distributed in upstream of 22 lncRNAs, downstream of 17 lncRNAs, overlapping regions of 48 lncRNAs, and antisense chains of 21 lncRNAs. Among down-regulated lncRNAs, mRNAs were distributed in upstream of 6 lncRNAs, downstream of 3 lncRNAs, overlapping regions of 10 lncRNAs, and antisense chains of 8 lncRNAs. Compared with the sham group, 1054 mRNA changed in the TBI group, of which 921 mRNA were up-regulated and 133 mRNA were down-regulated. The expression changes of ENSRNOT000063054, ENSRNOT000052790, ENSRNOT00000054410, ENSRNOT000063242, and ENSRNOT000069411 IncRNA regulate the expression of Top2a, RT1-CE11, Papss2, Stk32a, and Grid2 gene.

Conclusion

The present study detected the differential expression of lncRNAs and mRNAs in hippocampi of rats subjected to TBI, and discussed their relation, primarily.

MiRNA-124a: a Potential Biomarker for Neurological Deficits Following Cardiac Surgery in Pediatric Patients

Brain injury is a major source of patient morbidity after cardiac surgery in children. New early accurate biomarkers are needed for the diagnosis of patients at risk for cerebral postoperative damage. Specific circulating miRNAs have been found as suitable biomarkers for many diseases. We tested whether miRNA-124a reflects neurological injury in pediatric patients following heart surgery. Serum samples were obtained from 34 patients before and six hours after heart surgery. MiRNAs-124a was quantified by RQ-PCR. MiRNA-124a levels six hours after heart surgery correlated with the neurological outcome of the patients. In children with neurological deficits, miRNA-124a levels increased while in those with no neurological deficits the levels decreased. MiRNA-124a was able, at six hours after the operation, to identify patients who are at risk for the appearance of neurological deficits. Circulating miRNA-124a is a potential biomarker for the appearance of neurological deficits in pediatric patients following heart surgery. Graphical Abstract.

Spectral analysis of EEG in etiological assessment of patients with transient neurological deficits

OBJECTIVE

Differentiating transient ischemic attack from stroke mimics may be difficult. Besides clinical evaluation and brain imaging, electroencephalography (EEG) may be a useful diagnostic tool.

METHODS

We conducted spectral analysis on 67 EEG of patients who had presented a transient neurological deficit (TND) within the previous seven days. Expert clinicians provided the final diagnosis: transient ischemic attack, migraine with aura, focal seizure or "other". We first calculated the relative power of the four EEG frequency bands (delta, theta, alpha and beta), in the whole hemisphere, then, according to the clinical symptoms, in the relevant electrodes of the symptomatic hemisphere. Finally, we calculated the relative power ratio between symptomatic and asymptomatic hemispheres.

RESULTS

Median age was 60.6 years (57% females). The etiological diagnosis was transient ischemic attack (27%), migraine with aura (11%), focal seizures (22%) and "other" (40%). We did not find significant differences in the theta and delta relative power analysis between groups. Over the symptomatic hemisphere only, we found a significant increase of the alpha relative power (p = 0.0026, p < 0.0001, p = 0.0014) in the migraine group compared to transient ischemic attack, migraine and focal seizures groups, and a significant decrease of the beta relative power (p = 0.0034, p = 0.0016, p = 0.0005) compared to the same groups.

CONCLUSIONS

Migraine with aura presents a discriminative EEG relative power in comparison to transient neurological deficits of other origins. To further investigate the additive diagnosis value of EEG in other TND, future studies should be performed with an EEG obtained within the first 24 h after the onset of symptoms.

SIGNIFICANCE

Spectral EEG analysis discriminates migraine with aura groups from other groups, but not at the individual level.

Selective sphingosine-1-phosphate receptor 1 modulation ameliorates TBI-induced neurological deficit after CCI

BACKGROUND AND PURPOSE

The inflammatory response after traumatic brain injury (TBI) can contribute to secondary brain injury. RP101075, a sphingosine-1-phosphate receptor modulator, can attenuate various inflammatory responses. Here, we hypothesized that consecutive administration of RP101075 over 3 days could broadly suppress the TBI-induced inflammatory response and ameliorate the outcomes of TBI.

METHODS AND RESULTS

Young C57/BL6 mice were subjected to a controlled cortical impact (CCI) model. RP101075-treated mice exhibited significantly reduced scores on the modified neurological severity score (mNSS) test on days 3, 7, 14, and 21 after TBI, in comparison to TBI mice that received the vehicle. RP101075-treated mice had a remarkably decreased percentage of foot faults on the foot fault test on days 7, 14, and 21 after surgery, in comparison to TBI mice that received the vehicle. Using the wet brain weight/dry brain weight method, we found that RP101075 attenuated brain edema at 3 days post-TBI. According to the results of the Morris water maze (MWM), TBI mice treated with RP101075 exhibited reduced latency time and an increased percentage of target quadrant time from day 24 to day 25 after TBI, in comparison to TBI mice that received the vehicle. In addition, flow cytometry and immunohistochemistry showed that RP101075 markedly decreased the number of infiltrated T cells, B cells and NK cells at 3 days after TBI. Analysis of Western blot data showed that RP101075 lowered the expression of proinflammatory factors on day 3 after TBI.

CONCLUSIONS

Our study demonstrated that consecutive administration of RP101075 over 3 days suppressed the TBI-induced inflammatory response and ameliorated neurological deficits after TBI. Thus, this procedure may be a potential treatment strategy for TBI in the clinical setting.

HIF1A polymorphisms do not modify the risk of epilepsy nor cerebral palsy after neonatal hypoxic-ischemic encephalopathy

PURPOSE

Hypoxic-ischemic encephalopathy (HIE) remains the major cause of cerebral palsy and epilepsy in developed countries. Hypoxia-inducible factor 1 alpha (HIF-1α) is the key mediator of oxygen homoeostasis. The aim of this study was to investigate whether hypoxia-inducible factor 1 subunit alpha (HIF1A) functional polymorphisms are associated with the risk of epilepsy, drug-resistant epilepsy, and cerebral palsy after neonatal HIE.

METHODS

The study included 139 healthy controls and 229 patients with epilepsy and/or cerebral palsy, of which 95 had perinatal HIE. Genomic DNA isolated from buccal swabs or peripheral blood were genotyped for HIF1A rs11549465 and rs11549467 using PCR based methods.

RESULTS

The investigated HIF1A polymorphisms did not influence the risk of epilepsy and its drug-resistance nor cerebral palsy after neonatal HIE (all p > 0.05). Clinical characteristics of patients were significantly associated with neurological deficits after HIE.

CONCLUSION

This study found no statistically significant association of HIF1A rs11549465 and rs11549467 with the development of epilepsy and its drug-resistance, as well as cerebral palsy, after neonatal HIE.

Long-Term Independence in Older Patients with Aneurysmal Subarachnoid Hemorrhage in the Barrow Ruptured Aneurysm Trial

OBJECTIVE

Older patients have a higher risk for poor neurological outcomes following aneurysmal subarachnoid hemorrhage (aSAH). This study compared functional independence in older versus younger patients with aSAH and compared endovascular coiling with microsurgical clipping in the older cohort.

METHODS

Patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) with confirmed aSAH were analyzed. Patients were grouped by age: older (≥65 years old) or younger (<65 years old). The primary outcome analyzed was functional independence at long-term follow-up, defined as Barthel index >80 at 6-year follow-up. A second analysis was performed comparing functional independence in older patients treated with endovascular coiling versus microsurgical clipping.

RESULTS

Of 405 patients with aSAH enrolled in BRAT, 77 (19%) were ≥65 years old, and 328 (81%) were <65 years old. A lower percentage of older versus younger patients was functionally independent (Barthel index >80) at 6-year follow-up (42.0% [29/69] vs. 82.2% [217/264]; P < 0.001). A higher percentage of younger patients (69.7% [184/264]) had good neurological outcomes (modified Rankin Scale score <3) at 6-year follow-up compared with older patients (31.9% [22/69]; P < 0.001). A greater percentage of older patients treated with microsurgical clipping (51.0% [18/47]) versus endovascular coiling (22.7% [5/22]) had functional independence at 6-year follow-up (P < 0.04).

CONCLUSIONS

Patients ≥65 years old with aSAH are at increased risk for poor neurological outcomes compared with younger patients. Greater independence was observed in older patients after microsurgical clipping than after endovascular coiling at long-term follow-up.

Case report (precis): Atypical delayed presentation of cervical spinal epidural abscess

Background

Older patients with spinal epidural abscesses (SEA) may present in an atypical fashion, failing to exhibit the classical triad of pain, fever, and a neurological deficit. Rather, they may be less aware of pain, fail to develop a fever, and attribute their neurological deficit to "old age." Further, their laboratory studies may not be abnormal, and critical findings on MR (i.e., more so than CT studies) may be overlooked. Here, we present an elderly patient with severe upper extremity monoparesis whose cervical SEA was overlooked for months.

Case Description

Over 10 months, and 6 months ago respectively, the patient had two successive MR scans ordered due to falls; both were interpreted as normal. Within the past few months, a third cervical MR, and an initial CT scan were performed; they both showed "questionable" changes (e.g. cortical irregularity/epidural air) that were largely ignored. When the patient presented to a spine surgeon with severe upper extremity monoparesis, the fourth MR clearly demonstrated a high cervical SEA. Of interest, laboratory findings were normal (e.g. white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)). The patient successfully underwent an anterior cervical discectomy/and fusion (ACDF); cultures grew Staphylococcus aureus, and he was appropriately managed with intravenous antibiotic therapy.

Conclusion

This case report (precis) highlights three "teaching" points. First, elderly immunologically compromised patients may not develop the classical SEA triad of pain, fever, and a neurological deficit. Second, laboratory studies may remain normal. Third, it may take longer for abnormal findings to develop on MR/CT studies consistent with SEA in immunocompromised older patients, thus resulting in very delayed surgery.

Correlation analysis between serum procalcitonin and infarct volume in young patients with acute cerebral infarction

OBJECTIVE

To detect the serum procalcitonin (PCT) level and determine its relationship with the infarct volume in young patients with acute cerebral infarction.

METHODS

According to the infarct volume, young patients with acute cerebral infarction were divided into large group, intermediate group, and small group. The severity of clinical symptoms was determined according to the National Institute of Health Stroke Scale (NIHSS) score. Healthy young people were selected as the control group. Serum PCT levels were measured. The relationship among PCT, volume, and NIHSS score was analyzed.

RESULTS

PCT in observation group was significantly higher than that in control group (t = 6.879, P = 0.011), and PCT in severe group was significantly higher than in mild group (t = 6.978, P = 0.016). PCT in large cerebral infarction group was higher than that in intermediate and small-size infarct group (P = 0.0036 and P < 0.0001, respectively), and PCT in intermediate cerebral infarction group was higher than that in small-size infarct group (P = 0.0024). In observation group, the PCT level was positively correlated with both NIHSS (r = 0.793, P = 0.022) and infarction volume (r = 0.649, P = 0.007).

CONCLUSION

The level of PCT in young patients with acute cerebral infarction may be related to the inflammatory reaction of the cerebral artery and positively related to the volume of cerebral infarction and NIHSS score. To some extent, PCT concentration can predict the disease severity of acute cerebral infarction.

Traumatic lateral spondyloptosis of L2 with complete neurological deficit: A case report

Traumatic spondyloptosis of the lumbar spine is an uncommon and severe clinical entity, which is defined as complete fracture dislocation and subluxation (>100%) of one vertebral body in the coronal or sagittal plane from its adjacent vertebra. In coronal spondyloptosis the subluxated vertebral bodies lie beside each other, and the condition is lateraloptosis.

CLINICAL CASE

A male patient aged 56 years had multiple injures with complete neurological deficit. Computed tomography(CT) revealed as spondyloptosis, which L2 detached from the rest of the spine, spinal canal stenosis, sagittal imbalance, and angular kyphosis. We performed an en bloc corpectomy and iliac bone combined part of the vertebra body replanted in situ with posterior transpedicular fixation of T12-L4, with the sagittal balance recovered and motor function improved progressively.

CONCLUSION

Traumatic spondyloptosis requires an early resolution by a trained surgical team to ensure sagittal re-alignment for a progressive neurological recovery.

Severe hyponatremia with seizures and confirmed mild brain edema by hysteroscopic myomectomy: a case report

BACKGROUND

Hyponatremia can be developed during hysteroscopic surgery with electrolyte-free irrigation fluid. We experienced severe hyponatremia with postoperative seizures and confirmed mild brain edema.

CASE PRESENTATION

A quadragenarian female patient underwent a 2-h hysteroscopic myomectomy with electrolyte-free fluid for uterine distension under general anesthesia. Plasma sodium level of 84.1 mmol/L 100 min after the start of surgery indicated excessive absorption of the irrigation fluid. Acute severe hyponatremia was diagnosed with significant edema in the conjunctiva, lip, and extremities. She was treated with a continuous infusion of hypertonic saline. However, seizures and cerebral edema developed 7 h later. The patient recovered without neurological deficits at postoperative day 2.

CONCLUSION

The electrolyte-free irrigation fluid can be absorbed rapidly during hysteroscopic surgery. Its interruption with hyponatremia should be considered against prolonged surgery. Especially under general anesthesia, caution should be exercised because the typical symptoms of hyponatremia such as nausea and confusion are blinded.

Stem cell-based therapies for ischemic stroke: a systematic review and meta-analysis of clinical trials

Recently, extensive researches about stem cell-based therapies for ischemic stroke have been published; our review evaluated the efficacy and safety of stem cell-based therapies for ischemic stroke. Our review was registered on PROSPERO (http://www.crd.york.ac.uk/PROSPERO), registration number CRD42019135805. Two independent observers searched PubMed, EMBASE, Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), and Web of Science (Science Citation Index Expanded) for relevant studies up to 31 May 2019. We included clinical trials which compared efficacy outcomes (measured by National Institutes of Health Stroke Scale (NIHSS), modified Rankin scale (mRS), or Barthel index (BI)) and safety outcomes (such as death and adverse effects) between the stem cell-based therapies and control in ischemic stroke. We performed random effect meta-analysis using Review Manager 5.3. Our review included nine randomized controlled trials (RCTs) and seven non-randomized studies (NRSs), involving 740 participants. Stem cell-based therapies were associated with better outcomes measured by NIHSS (mean difference (MD) − 1.63, 95% confidence intervals (CI) − 2.73 to − 0.53, I² =60%) and BI (MD 14.68, 95% CI 1.12 to 28.24, I² = 68%) in RCTs, and by BI (MD 6.40, 95% CI 3.14 to 9.65, I² = 0%) in NRSs. However, the risk of bias was high and the efficacy outcomes of RCTs were high heterogeneity. There was no significant difference in mortality between the stem cell group and the control group. Fever, headache, and recurrent stroke were the most frequently reported adverse effects. Our review shows that stem cell-based therapies can improve the neurological deficits and activities of daily living in patients with ischemic stroke.

Combined prognostic significance of D-dimer level and platelet count in acute ischemic stroke

BACKGROUND

D-dimer level and platelet count (PC) have been reported separately as significant independent predictors of Acute Ischemic Stroke (AIS). Here, we aimed to investigate the combined prognostic value of abnormal D-dimer level and PC as defined for specific in-hospital and long-term outcomes in AIS patients.

METHODS

A total of 1468 patients admitted for ischemic stroke within 24 h of symptom onset from April 1, 2016 to November 31, 2019 at the Department of Neurology, the First Affiliated Hospital of Harbin Medical University were included in the final analysis. Eligible subjects were divided into four groups in terms of their levels of D-dimer and PC: DD-PC- (normal D-dimer level and normal PC), DD-PC+ (normal D-dimer level and abnormal PC), DD+PC- (higher D-dimer level and normal PC), and DD+PC+ (higher D-dimer level and abnormal PC). Logistic regression model and multinomial logit model were used to estimate the combined effect of D-dimer level and PC on in-hospital outcomes including discharge outcome and early neurological changes, and poor outcomes at 3, 6 and 12 months.

RESULTS

DD+PC+ was found to be associated with the risk of in-hospital mortality (adjusted odds ratio [OR], 6.904; 95% confidence interval [CI], 2.781-17.144) and 3-month mortality (adjusted OR, 5.455; 95% CI, 2.019-14.743) compared with DD-PC-. Combination of the two indicators significantly improved the independent predictive value for functional outcomes, including early neurological deterioration (END) (OR, 3.622; 95% CI, 1.732-7.573) with threshold of at least 4-point increase on NIHSS, discharge outcome (OR, 2.713; 95% CI, 1.421-5.177); mRS of 0-1 point (OR, 0.409; 95% CI, 0.211-0.792), mRS of 0-2 points (OR, 0.234; 95% CI, 0.118, 0.461), and higher mRS-shift (OR, 2.379; 95% CI, 1.237-4.576) at 3 months; unfavorable outcome at 3 months (OR, 4.280; 95% CI, 2.169-8.446), 6 months (OR, 3.297; 95% CI, 1.452-7.488) and 12 months (OR, 4.157; 95% CI, 1.598-10.816). While comparatively weaker statistical significance was shown in DD+PC- and no correlation was found between adverse outcomes and DD-PC+. Similarly, patients with abnormal D-dimer level and PC were less likely to reach the status of stable or improving.

CONCLUSIONS

Combination of D-dimer level and PC may have more significant prognostic value on END, in-hospital mortality, discharge outcome, and long-term outcomes than either index of D-dimer level or PC alone in AIS patients.

Predictive factors of postoperative deficit and functional outcome after surgery for upper limb schwannomas: Retrospective study of 21 patients

Schwannomas are the most frequent benign tumors of the peripheral nerves. Tumor enucleation is the traditional surgical treatment. The incidence of neurological complications after surgery varies and predictive factors for these complications are not clearly defined. The aim of this study was to find predictive factors of postoperative neurological deficit after surgical treatment of schwannomas of the upper limb. Twenty-four schwannomas removed from 21 patients were analyzed retrospectively. The patients' mean age was 45.4years and the mean follow-up was 64.4months. Clinical parameters studied were age, gender, nature of preoperative symptoms, duration of symptoms, type of surgery performed, tumor location and size, nerve involved, QuickDASH and DN4 scores. Postoperative neurological deficits occurred in 14 patients (67%), with 11 having a sensory deficit and 7 a motor weakness. Eleven did not exist before surgery (6 sensory, 5 motor). In the postoperative deficit subgroup, 6 schwannomas involved the brachial plexus, 4 the ulnar nerve, and 4 the median nerve. All patients who had a fascicular resection because tumor enucleation was not feasible were in the postoperative deficit subgroup. Ten patients had either unchanged or worse QuickDASH and/or DN4 scores after surgery. Surgical treatment of schwannomas can lead to postoperative complications. Although none of our findings were statistically significant, advanced age, large tumor size, more than 16months between the first symptoms and surgery, and brachial plexus location seem to be more frequently observed in those with a postoperative neurological deficit.

Intraoperative neurophysiology in pediatric supratentorial surgery: experience with 57 cases

PURPOSE

Utilization of intraoperative neurophysiology (ION) to map and assess various functions during supratentorial brain tumor and epilepsy surgery is well documented and commonplace in the adult setting. The applicability has yet to be established in the pediatric age group.

METHODS

All pediatric supratentorial surgery utilizing ION of the motor system, completed over a period of 10 years, was analyzed retrospectively for the following variables: preoperative and postoperative motor deficits, extent of resection, sensory-motor mappability and monitorability, location of lesion, patient age, and monitoring alarms. Intraoperative findings were correlated with antecedent symptomatology as well as short- and long-term postoperative clinical outcome. The monitoring impact on surgical course was evaluated on a per-case basis.

RESULTS

Data were analyzed for 57 patients (ages 3-207 months (93 ± 58)). Deep lesions (in proximity to the pyramidal fibers) constituted 15.7% of the total group, superficial lesions 47.4%, lesions with both deep and superficial components 31.5%, and ventricular 5.2%. Mapping of the motor cortex was significantly more successful using the short-train technique than Penfield's technique (84% vs. 25% of trials, respectively), particularly in younger children. The youngest age at which motor mapping was successfully achieved was 3 vs. 93 months for each method, respectively. Preoperative motor strength was not associated with monitorability. Direct cortial motor evoked potential (dcMEP) was more sensitive than transcranial (tcMEP) in predicting postoperative motor decline. dcMEP decline was not associated with tumor grade or extent of resection (EOR); however, it was associated with lesion location and more prone to decline in deep locations. ION actively affected surgical decisions in several aspects, such as altering the corticectomy location and alarming due to a MEP decline.

CONCLUSION

ION is applicable in the pediatric population with certain limitations, depending mainly on age. When successful, ION has a positive impact on surgical decision-making, ultimately providing an added element of safety for these patients.

A new decompression technique for upper lumbar fracture with neurologic deficit-comparison with traditional open posterior surgery

Background

Surgery is usually recommended for thoracolumbar fracture with neurologic deficit. However, traditional open posterior approach requires massive paraspinal muscles stripping, and the canal decompression may be limited and incomplete. We aimed to investigate a new approach via the Wiltse approach and the Kambin’s Triangle.

Methods

Twenty-one consecutive patients with traumatic upper lumbar fracture who received this new approach surgery between January 2015 and January 2016 constituted the new approach group. Twenty-nine patients received the traditional open posterior surgery between January 2014 and January 2015 were classified as the traditional posterior surgery group. Surgical informations including operative time, blood loss, drainage volume, hospitalization days were collected and compared among the two groups. The American Spinal Injury Association (ASIA) impairment scale and Visual Analog Score (VAS) were evaluated preoperatively, postoperatively and at 12 months follow-up.

Results

Patients in the new approach group had fewer operation time (128.3 ± 25.1 vs 151 ± 32.2 min, P = 0.01), less blood loss (243.8 ± 135.5 vs 437.8 ± 224.9 ml, P = 0.001) and drainage volume (70.7 ± 57.2 vs 271.7 ± 95.5 ml, P < 0.001), as well as shorter hospitalization stay than the traditional posterior surgery group (6.6 ± 1.8 vs 8.5 ± 2.4 d, P = 0.004). Similar neurologic recovery according to ASIA grade was achieved in both groups (Recovery index: 0.90 ± 0.53 vs 0.86 ± 0.51, P = 0.778). While the pain level was significantly lower in the new approach group postoperatively (2.6 ± 0.7 vs 3.5 ± 0.9, P < 0.001) and at 12 months follow-up (1.4 ± 0.9 vs 2.4 ± 0.8, P < 0.001).

Conclusion

The present new approach was successfully applied in the treatment of upper lumbar fracture with neurologic deficit. It can reduce iatrogenic trauma and achieve similar or better outcomes compared to the traditional posterior surgery.