Cilostazol addition to aspirin may worsen the short-term outcome in patients with large artery disease: ADS subanalysis

BACKGROUND

Our previous acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of neurological deterioration in non-cardioembolic stroke patients. In this post-hoc analysis, we investigated whether the impact of dual antiplatelet therapy (DAPT) may depend on neurological severity, as represented by large artery disease.

METHODS

Neurological deterioration was defined as neurological progression with an increment of the National Institutes of Health Stroke Scale (NIHSS) score of ≥2. NIHSS score subgroups were divided into that of 0-1, 2-4, 5-10, and >10.

RESULTS

Among 1014 patients, 203 (20%) had the large artery disease, and 811 (80%) did not. In the total cohort, the rate of neurological deterioration was 10.8% in the DAPT group and 8.3% in the aspirin group (P = 0.197). When we focused on the large artery disease group, DAPT group had a higher rate of neurological deterioration as 18.3% compared to 8.2% in the aspirin group (P = 0.036). Among patients with NIHSS score of 0-1 and 2-4, the rates of neurological deterioration were not different between the two group (both, P = 1.000). However, when NIHSS score elevated to 5-10, 45% in the DAPT group and 9.1% in the aspirin group deteriorated (P = 0.013). Among the patients with NIHSS score of >10, 60% in the DAPT group and none (0%) in the aspirin group had the neurological deterioration (P = 0.045).

CONCLUSION

DAPT with aspirin and cilostazol was associated with higher rate of neurological deterioration when patients have large artery disease and not mild neurological deficits.

Early neurological deterioration in Wilson's disease: a systematic literature review and meta-analysis

INTRODUCTION

Neurological deterioration, soon after anti-copper treatment initiation, is problematic in the management of Wilson's disease (WD) and yet reports in the literature are limited. The aim of our study was to systematically assess the data according to early neurological deteriorations in WD, its outcome and risk factors.

METHODS

Using PRISMA guidelines, a systematic review of available data on early neurological deteriorations was performed by searching the PubMed database and reference lists. Random effects meta-analytic models summarized cases of neurological deterioration by disease phenotype.

RESULTS

Across the 32 included articles, 217 cases of early neurological deterioration occurred in 1512 WD patients (frequency 14.3%), most commonly in patients with neurological WD (21.8%; 167/763), rarely in hepatic disease (1.3%; 5/377), and with no cases among asymptomatic individuals. Most neurological deterioration occurred in patients treated with d-penicillamine (70.5%; 153/217), trientine (14.2%; 31/217) or zinc salts (6.9%; 15/217); the data did not allow to determine if that reflects how often treatments were chosen as first line therapy or if the risk of deterioration differed with therapy. Symptoms completely resolved in 24.2% of patients (31/128), resolved partially in 27.3% (35/128), did not improve in 39.8% (51/128), with 11 patients lost to follow-up.

CONCLUSIONS

Given its occurrence in up to 21.8% of patients with neurological WD in this meta-analysis of small studies, there is a need for further investigations to distinguish the natural time course of WD from treatment-related early deterioration and to develop a standard definition for treatment-induced effects.

Culprit Plaques of Large Parent Arteries, Rather than Cerebral Small Vessel Disease, Contribute to Early Neurological Deterioration in Stroke Patients with Intracranial Branch Atheromatous Disease

INTRODUCTION

Intracranial branch atheromatous disease (BAD) has been applied to occlusions that occur at the origin of large caliber penetrating arteries due to the microatheromas or large parent artery plaques. This study aimed to explore the association between culprit plaques of large parent arteries, neuroimaging markers of cerebral small vessel disease (CSVD), and the risk of early neurological deterioration (END) in stroke patients with BAD.

METHODS

A total of 97 stroke patients with BAD in the vascular territories of the lenticulostriate arteries or paramedian pontine arteries, diagnosed using high-resolution magnetic resonance imaging, were prospectively recruited in this observational study. A culprit plaque in the middle cerebral artery was defined as the only arterial plaque on the ipsilateral side of an infarction visible on diffusion-weighted imaging. A culprit plaque in the basilar artery (BA) was identified when it was observed within the same axial slices of an infarction or on the adjacent upper or lower slice, whereas a plaque within the BA located in the ventral region was considered non-culprit. If more than one plaque was present in the same vascular territory, the most stenotic plaque was chosen for the analysis. Four CSVD neuroimaging markers, including white matter hyperintensity, lacunes, microbleeds, and enlarged perivascular spaces, were evaluated in accordance with the total CSVD score. The associations between neuroimaging features of lesions within large parent arteries, neuroimaging markers of CSVD, and the risk of END in stroke patients with BAD were investigated using logistic regression analysis.

RESULTS

END occurred in 41 stroke patients (42.27%) with BAD. The degree of large parent artery stenosis (p < 0.001), culprit plaques of large parent arteries (p < 0.001), and plaque burden (p < 0.001) were significantly different between the END and non-END groups in stroke patients with BAD. In logistic regression analysis, culprit plaques of large parent arteries (odds ratio, 32.258; 95% confidence interval, 4.140-251.346) were independently associated with the risk of END in stroke patients with BAD.

CONCLUSIONS

Culprit plaques of large parent arteries could predict the risk of END in stroke patients with BAD. These results suggest that lesions in the large parent arteries, rather than damage to the cerebral small vessels, contribute to END in stroke patients with BAD.

Morphological predictors of neurological deterioration in patients with acute isolated pontine infarct

OBJECTIVE

To investigate morphological predictors of neurological deterioration (ND) in patients with acute isolated pontine infarct.

METHODS

Acute isolated pontine infarct patients within 7 days after onset of stroke symptoms were included retrospectively and classified into ND and non-ND groups. Morphological phenotypes (paramedian pontine infarct [PPI], atypical PPI, small deep infarct, and other types), topographical location, and lesion size were evaluated on axial diffusion-weighted imaging.

RESULTS

There were 210 eligible patients, of whom 62 patients had ND (29.5%). The proportion of PPI was significantly higher in ND than that in non-ND (62.9% vs 39.6%). ND occurred more frequently in PPI patients than non-PPI patients (39.8% vs 20.5%). PPI located more frequently in lower pontine (20.4% vs 8.0%) and less in upper pontine (17.3% vs 30.4%, P = 0.028), and had larger ventro-dorsal length (13.8 ± 3.8 vs 9.9 ± 3.1) and width (8.3 ± 2.3 vs 6.2 ± 1.8) than non-PPI patients. The morphological phenotype of PPI was an independent risk factor for ND (OR 4.81, 95%CI 1.54-15.07, P = 0.007) in patients with isolated pontine infarct. The ventro-dorsal length of pontine infarct lesion was associated with ND (OR 1.18, 95%CI 1.01, 1.37, P = 0.034) in PPI patients.

CONCLUSIONS

The morphological phenotype of PPI was a potential predictor for ND in patients with acute isolated pontine infarct. The ventro-dorsal length of pontine infarct lesion was possibly associated with ND in PPI patients.

Complication Avoidance in Spine Surgery

The outcomes of spine surgery are closely related to postoperative morbidity. Therefore, an experienced surgeon must be aware of various complications and should apply all necessary preventive measures to avoid them. It is widely considered that complications of spine surgery are underreported and that their real incidence is much higher than expected. This review highlights methods to prevent various types of morbidity that may be encountered during different spinal procedures, considering general complications, approach-related complications, fusion- and implant-related complications, and systemic complications.

Association between premorbid sarcopenia and neurological deterioration in patients with acute ischemic stroke

OBJECTIVE

Sarcopenia is associated with poor outcomes in patients with stroke. This study aimed to investigate the association between premorbid sarcopenia and neurological deterioration (ND) in patients with acute ischemic stroke. To the best of our knowledge, there have been no studies on this topic.

METHODS

In this prospective longitudinal study, we assessed premorbid sarcopenia using the SARC-F questionnaire, and the incidence of ND was defined by an increase of ≥ 1 point on the National Institutes of Health Stroke Scale (NIHSS) or the occurrence of any new neurological symptoms/signs. Logistic regression analysis was used to investigate the relationship between premorbid sarcopenia and ND.

RESULTS

Of the 290 patients enrolled, 46 and 244 patients experienced and did not experience ND 1 week after admission (ND and non-ND groups, respectively). The prevalence of sarcopenia was significantly higher in the ND group than in the non-ND group (39% vs. 17%). In the adjusted model, premorbid sarcopenia was significantly associated with ND (adjusted odds ratio: 3.06, 95% confidence interval: 1.11-8.40; p = 0.03).

CONCLUSION

Premorbid sarcopenia is independently associated with ND in patients with acute ischemic stroke. Therefore, it is necessary to detect premorbid sarcopenia to predict ND in these patients.

Serum neurofilament light chain and initial severity of neurological disease predict the early neurological deterioration in Wilson's disease

Background

In Wilson’s disease (WD), early neurological deterioration after treatment initiation is associated with poor outcomes; however, data on this phenomenon are limited. Our study analysed the frequency and risk factors of early neurological deterioration in WD.

Methods

Early neurological deterioration, within 6 months from diagnosis, was defined based on the Unified Wilson’s Disease Rating Scale (UWDRS): any increase in part II or an increase of ≥ 4 in part III. In total, 61 newly diagnosed WD patients were included. UWDRS scores, brain magnetic resonance imaging (MRI) scores, copper metabolism parameters, treatment type and serum neuro-filament light chain (sNfL) concentrations at diagnosis were analysed as potential risk factors of early deterioration.

Results

Early neurological deterioration was observed in 16.3% of all WD patients; all cases of worsening occurred in the neurological phenotype (27.7%). Higher scores were seen in those who deteriorated compared with those who did not for UWDRS part II (4.3 ± 5.0 vs 2.0 ± 5.9; p < 0.05), UWDRS part III (21.5 ± 14.1 vs 9.3 ± 16.4; p < 0.01) and MRI-assessed chronic damage (3.2 ± 1.6 vs 1.4 ± 2.2; p = 0.006); all these variables indicated the initial severity of neurological disease. Pre-treatment sNfL concentrations were significantly higher in patients who deteriorated compared with those who did not (33.2 ± 23.5 vs 27.6 ± 62.7 pg/mL; p < 0.01). In univariate logistic regression amongst all patients, chronic damage MRI scores, UWDRS part III scores and sNfL concentrations predicated early deterioration. In the neurological WD, only sNFL were a significant predictor. In bivariate logistic regression amongst all patients, sNfL remained the only significant predictor of deterioration when corrected for MRI scores.

Conclusion

sNfL concentrations are a promising biomarker of the risk of early neurological deterioration in WD.

Baseline platelet count may predict short-term functional outcome of cerebral infarction

Background and aims

Platelets play an important role in homeostasis however, they have also been associated with increased mortality after myocardial infarction. In the present study, we investigated whether platelet count is associated with differences in the short-term prognosis at the time of hospital discharge and early neurological deterioration in ischemic stroke patients.

Methods

Patients with ischemic stroke were enrolled from among 661 cerebrovascular disease patients admitted between January 2018 and December 2020. Patients who received hyperacute treatment, had a pre-onset modified Rankin scale (mRS) ≥ 3, transient ischemic attack, or active malignant disease were excluded. The platelet count was divided into quartiles (Q1-4) according to the number of patients, and the relationship between platelet count and prognosis was assessed using multivariable analysis.

Results

In total, 385 patients were included in the study. Regarding the functional outcome by platelet count, there was a significant increase in mRS ≥ 3 at discharge in the Q4 (range: 243–1327 × 10⁹/L, p = 0.013, ORs: 1.674, 95%CI: 1.253–6.681) group compared to the Q3 (range: 205–242 × 10⁹/L) group even after adjusting for factors with P < 0.2 in univariate analysis. Furthermore, the frequency of neurological deterioration (NIHSS ≥ 4) within 1 week was significantly lower in the Q3 group than in the Q1 (range; 19–173 × 10⁹/L) and Q4 groups even after adjustment (Q1; p = 0.020 ORs: 6.634, 95%CI: 1.352–32.557, Q4; p = 0.007 ORs: 8.765, 95%CI: 1.827–42.035).

Conclusion

Platelet count at onset may affect the prognosis of cerebral infarction and early neurological deterioration. This study may help clarify the pathogenesis of cerebral infarction to improve prognosis.

Relationship Between Body Temperature and Early Neurological Deterioration after Endovascular Thrombectomy for Acute Ischemic Stroke with Large Vessel Occlusion

BACKGROUND

Early neurological deterioration (END) after endovascular thrombectomy (EVT) is strongly associated with poor prognosis in patients with large vessel occlusion. The relationship between body temperature and END after EVT is unknown, which we aimed to investigate in this study.

METHODS

END was defined as an increase of four or more points on the National Institutes of Health Stroke Scale score compared with the baseline assessment within 24 h. Logistic regression and restricted cubic spline models were used to assess the relationship between body temperature and END.

RESULTS

Among 7741 consecutive patients with ischemic stroke, 406 patients with large vessel occlusion who underwent EVT were enrolled. In total, 88 (21.7%) patients developed END. Logistic regression showed that the maximum body temperature within 24 h (odds ratio [OR] = 1.97 per °C, 95% confidence interval [CI] 1.17-3.32, p = 0.010) was independently associated with END. This association was nonlinear and J shaped (p for nonlinearity = 0.010), and the risk of END increased when the maximum body temperature within 24 h was lower or higher than 37.0 °C. Fever burden is also independently associated with END (OR = 1.06 per °C  × hour, 95% CI 1.01-1.11, p = 0.012). In addition, the timing of fever onset was independently associated with END, and the highest risk of END was associated with fever onset within 6 h after EVT (OR = 3.92, 95% CI 1.25-12.27, p = 0.019).

CONCLUSIONS

In summary, there is a J-shaped association between the maximum body temperature within 24 h after EVT and END. Moreover, the risk of END differed according to the timing of fever onset.

Impact of Perihematomal Edema on Infectious Complications after Spontaneous Intracerebral Hemorrhage

OBJECTIVE

Intracerebral hematoma involves two mechanisms leading to brain injury: the mechanical disruption of adjacent brain tissue by the hematoma and delayed neurological injury. Delayed neurological injury involves perihematomal edema (PHE) formation. Infectious complications following intracerebral hemorrhage (ICH) are a significant contributor to post-ICH recovery. We sought to identify a correlation between PHE volumes and infectious complications following ICH. We also sought to explore the clinical impact of this association.

MATERIALS AND METHODS

This retrospective study included 143 patients with spontaneous ICH. CT scans were performed on admission, and 3 h, 24 h, and 72 h following admission. Hematoma and PHE volumes were calculated using a semi-automatic method. The absolute PHE volume at each time point and changes in PHE volume (ΔPHE) were calculated. Neutrophil to lymphocyte ratio (NLR) and serum C-reactive protein (CRP) levels were measured from the obtained blood samples. Neurological deterioration (ND) was assessed in all patients.

RESULTS

Infectious complications were associated with ΔPHE_72-24 (P < 0.01), whereas there was no association between infectious complications and ΔPHE_24-3 (P = 0.09) or ΔPHE_3-ad (P = 0.81). There was a positive correlation between ΔPHE_72-24 and NLR (r = 0.85, 95% CI: 0.79-0.90, P < 0.01) and between ΔPHE_72-24 and CRP levels (r = 0.89, 95% CI: 0.84-0.92, P < 0.01). The ND rate in the group of patients with infectious complications comorbid with high ΔPHE_72-24 was higher than the other patient groups (P < 0.01).

CONCLUSIONS

This study revealed a correlation between ΔPHE_72-24 and infectious complications after spontaneous ICH, which was associated with markers of systemic inflammation. This phenotype linkage is a negative cascade that drives ND.

Risk factors associated with post-operative neurological deterioration in patients with thoracic disc disorders with myelopathy

PURPOSE

Post-operative neurological deterioration (ND) is a severe complication. However, limited literature exists on the ND in thoracic disc disorders with myelopathy (TDM). This study describes the risk factors of neurological deterioration in TDM with instrumentation and fusion.

METHODS

A single-centre review of TDM with instrumentation and fusion during 2006-2019 was performed. Post-operative neurological deterioration was defined as the deterioration of pre-existing neurological function or the appearance of new neurological symptoms. Patients were then grouped into two groups depending on neurological deterioration (ND group) or not (non-ND group). Demographics, radiographic parameters, and surgical characteristics were compared between the two groups.

RESULTS

A total of 257 cases were included, and neurological deterioration occurred in 16 (6.23%) cases. Multivariate analysis revealed spinal canal occupancy ratio > 75%, U-shaped compressed spinal cord in axial MRI, calcified herniated disc, anterior approach, and intra-operative blood loss > 1500 mL were associated with ND. Ten patients (62.5%) had complete neurological recovery within six months, and four patients (25%) had progressive neurological function improvement and equal or better than pre-operation within nine months.

CONCLUSIONS

The rate of neurological deterioration is 6.23%, and a higher spinal canal occupancy ratio, U-shaped compressed spinal cord, calcified herniated disc, anterior approach, and massive intra-operative blood loss were associated with neurological deterioration. Long-term outcomes of neurological deterioration are favourable, and 62.5% of patients experienced complete neurological recovery within six months. Patients with TMD who undergo surgery should be properly informed of the potential risks of neurological deterioration, despite its usually transient nature in most patients.

Predictors and Outcomes of Neurological Deterioration in Intracerebral Hemorrhage: Results from the TICH-2 Randomized Controlled Trial

Neurological deterioration is common after intracerebral hemorrhage (ICH). We aimed to identify the predictors and effects of neurological deterioration and whether tranexamic acid reduced the risk of neurological deterioration. Data from the Tranexamic acid in IntraCerebral Hemorrhage-2 (TICH-2) randomized controlled trial were analyzed. Neurological deterioration was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) of ≥ 4 or a decline in Glasgow Coma Scale of ≥ 2. Neurological deterioration was considered to be early if it started ≤ 48 h and late if commenced between 48 h and 7 days after onset. Logistic regression was used to identify predictors and effects of neurological deterioration and the effect of tranexamic acid on neurological deterioration. Of 2325 patients, 735 (31.7%) had neurological deterioration: 590 (80.3%) occurred early and 145 (19.7%) late. Predictors of early neurological deterioration included recruitment from the UK, previous ICH, higher admission systolic blood pressure, higher NIHSS, shorter onset-to-CT time, larger baseline hematoma, intraventricular hemorrhage, subarachnoid extension and antiplatelet therapy. Older age, male sex, higher NIHSS, previous ICH and larger baseline hematoma predicted late neurological deterioration. Neurological deterioration was independently associated with a modified Rankin Scale of > 3 (aOR 4.98, 3.70-6.70; p < 0.001). Tranexamic acid reduced the risk of early (aOR 0.79, 0.63-0.99; p = 0.041) but not late neurological deterioration (aOR 0.76, 0.52-1.11; p = 0.15). Larger hematoma size, intraventricular and subarachnoid extension increased the risk of neurological deterioration. Neurological deterioration increased the risk of death and dependency at day 90. Tranexamic acid reduced the risk of early neurological deterioration and warrants further investigation in ICH. URL: https://www.isrctn.com Unique identifier: ISRCTN93732214.

Combined dimercaptosuccinic acid and zinc treatment in neurological Wilson's disease patients with penicillamine-induced allergy or early neurological deterioration

The clinical data of safety and efficacy of a combined treatment with dimercaptosuccinic acid (DMSA) and Zinc with 2 years’ follow-up in 60 neurological Wilson’s disease (WD) patients was retrospectively analyzed. All the patients included in the present study were newly diagnosed and initialized with D-penicillamine (DPA) treatment but were found to have either neurological deterioration or allergy, and their treatment was switched to a combined treatment of DMSA and Zinc. Fifty-one patients (85%) had the neurological symptoms improved 1 and 2 years after treatment, 7 (11.67%) experienced a stable neurological condition, and 2 (3.33%) suffered deterioration of neurological symptoms. No early neurological deterioration was observed in all patients. Twenty-five percent patients experienced mild adverse reactions which did not require a discontinuation of the DMSA and Zinc treatment. Our study confirmed the safety and efficacy of the combined DMSA and Zinc therapy as an initial and probably long-term treatment in neurological WD patients.

Late Neurological Deterioration after Acute Intracerebral Hemorrhage: A post hoc Analysis of the ATACH-2 Trial

BACKGROUND

Neurological deterioration (ND) has a major influence on the prognosis of intracerebral hemorrhage (ICH); however, factors associated with ND occurring after 24 h of ICH onset are unknown.

METHODS

We performed exploratory analyses of data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial, which compared intensive and standard blood pressure lowering treatment in ICH. NDs were captured on the adverse event case report form. Logistic regression analysis was performed to examine the independent predictors of late ND.

RESULTS

Among 1,000 participants with acute ICH, 82 patients (8.2%) developed early ND (≤24 h), and 64 (6.4%) had late ND. Baseline hematoma volume (adjusted OR [aOR] per 1-cm3 increase 1.04, 95% CI 1.02-1.06, p < 0.0001), hematoma volume increase in 24 h (aOR 2.24, 95% CI 1.23-4.07, p = 0.008), and the presence of intraventricular hemorrhage (IVH; aOR 2.38, 95% CI 1.32-4.29, p = 0.004) were independent predictors of late ND (vs. no late ND). Late ND was a significant risk factor for poor 90-day outcome (OR 3.46, 95% CI 1.82-6.56). No statistically significant difference in the incidence of late ND was noted between the 2 treatment groups.

CONCLUSIONS

Initial hematoma volume, early hematoma volume expansion, and IVH are independent predictors of late ND after ICH. Intensive reduction in the systolic blood pressure level does not prevent the development of late ND.

Schaaf-Yang syndrome shows a Prader-Willi syndrome-like phenotype during infancy

Background

Schaaf-Yang syndrome (SYS) is a newly recognized imprinting related syndrome, which is caused by a truncating variant in maternally imprinted MAGEL2 located in 15q11-q13. Yet, precise pathomechanism remains to be solved. We sequenced MAGEL2 in patients suspected Prader-Willi syndrome (PWS) to delineate clinical presentation of SYS. We examined 105 patients with clinically suspected PWS but without a specific PWS genetic alteration. Sanger sequencing of the entire MAGEL2 gene and methylation-specific restriction enzyme treatment to detect the parent of origin were performed. Clinical presentation was retrospectively assessed in detail.

Results

Truncating variants in MAGEL2 were detected in six patients (5.7%), including a pair of siblings. All truncating variants in affected patients were on the paternally derived chromosome, while the healthy father of the affected siblings inherited the variant from his mother. Patients with MAGEL2 variants shared several features with PWS, such as neonatal hypotonia, poor suck, and obesity; however, there were also unique features, including arthrogryposis and a failure to acquire meaningful words. Additionally, an episode of neurological deterioration following febrile illness was confirmed in four of the six patients, which caused severe neurological sequalae.

Conclusions

SYS can be present in infants suspected with PWS but some unique features, such as arthrogryposis, can help discriminate between the two syndromes. An episode of neurological deterioration following febrile illness should be recognized as an important complication.

Complications Associated with Surgery for Thoracic Disc Herniation: A Systematic Review and Network Meta-Analysis

BACKGROUND

A systematic review and network meta-analysis (Prospero ID CRD42018106936) were performed.

OBJECTIVE

The selection of the appropriate surgical approach for the management of thoracic disc herniation (TDH) is often challenging because of the frequency and variability of the associated complications. We evaluated the safety of the surgical approaches for TDH by estimating the mortality (Q1) and morbidity (Q2), and frequency of the most common complications (Q3).

METHODS

We searched the medical literature for randomized controlled trials and observational studies reporting on the management of TDH. Postoperative complications were the outcome of interest. The absolute and relative risk estimates, along with the rank probability scores, were estimated for each approach, through a network meta-analysis. The results were read in the light of the quality of the available evidence.

RESULTS

Fifteen studies with a total of 1036 patients fulfilled our eligibility criteria. Three deaths were reported. The overall morbidity was as high as 29%, largely attributed to medical (21%; 95% confidence interval [CI], 10%-38%), surgical site (11%; 95% CI, 5%-22%), cerebrospinal fluid-related (8%; 95% CI, 3%-8%), and neurologic complications (5%; 95% CI, 1%-24%). The anterior and lateral approaches were associated with a higher risk for medical and surgical complications compared with the posterolateral approach.

CONCLUSIONS

Surgery for TDH is associated with minimal mortality but significant morbidity, with large variations among the available approaches. An understanding of the perioperative complications rates is important to develop complication avoidance strategies and to aid accurate patient-to-doctor communication.

Unplanned Second-Stage Decompression for Neurological Deterioration Caused by Central Canal Stenosis after Indirect Lumbar Decompression Surgery

Study Design

Prospective cohort study.

Purpose

This study aimed to identify risk factors for unplanned second-stage decompression for postoperative neurological deficit after indirect decompression using lateral lumbar interbody fusion (LLIF) with posterior fixation.

Overview of Literature

Indirect lumbar decompression with LLIF has been used as a minimally invasive alternative to direct decompression to treat degenerative lumbar diseases requiring neural decompression. However, evidence on the prevalence of neurological deficits caused by spinal canal stenosis after indirect decompression is limited.

Methods

This study included 158 patients (mean age, 71.13±7.98 years; male/female ratio, 67/91) who underwent indirect decompression with LLIF and posterior fixation. Indirect decompression was performed at 271 levels (mean level, 1.71±0.97). Logistic regression analysis was used to identify the risk factors for postoperative neurological deficits. The variables included were age, sex, body mass index, presence of primary diseases, diabetes mellitus, preoperative motor deficit, levels operated on, preoperative severity of lumbar stenosis, and preoperative Japanese Orthopedic Association (JOA) score.

Results

Postoperative neurological deficit due to spinal canal stenosis occurred in three patients (1.9%). Spinal stenosis due to hemodialysis (p<0.001), ligament ossification (p<0.001), presence of preoperative motor paralysis (p<0.001), low JOA score (p=0.004), and severe canal stenosis (p=0.02) were significantly more frequent in the paralysis group.

Conclusions

Severe preoperative canal stenosis and neurological deficit were identified as risk factors for postoperative neurological deterioration caused by spinal canal stenosis. Additionally, uncommon diseases, such as spinal stenosis due to hemodialysis and ligament ossification, increased the risk of postoperative neurological deficit; therefore, in such cases, indirect decompression is contraindicated.

Evaluation of efficacy and safety of gandouling plus sodium dimercaptosulphonate in treatment of patients with neurological Wilson's disease from China

OBJECTIVE

To evaluate the efficacy and safety of gandouling plus sodium dimercaptosulphonate (DMPS) on neurological Wilson's disease (WD) in patients.

METHODS

We retrospectively evaluated the clinical records of 125 WD patients with neurological syndromes who were treated with gandouling plus sodium DMPS or DMPS used alone. All patients had a history of neurological deterioration during their diseases courses. The clinical efficacies, adverse reactions, and results of the various hematological and biochemical investigations were recorded for statistical analysis.

RESULTS

92.30% (60 patients) of the WD patients treated with the combined therapy experienced an improved or stable neurological condition paralleled by a significantly improved GAS score. Meanwhile, the WBC and PLT counts stabilized, liver function and renal function were improved or remained stable. The combined therapy also obviously promoted the 24-h urinary copper excretion. In particular, only 30.76% of the WD patients experienced mild adverse reactions, including neurological deterioration in 5 patients (7.69%), hepatic worsening in 1 subject (1.89%), which was less frequently than those in the control group treated with DMPS only.

CONCLUSION

Our findings indicate that the safety and efficacy of gandou-ling plus DMPS is superior to those of DMPS used alone in the WD patients with neurological symptoms.

Predictive factors for neurological deterioration after surgical decompression for thoracic ossified yellow ligament

PURPOSE

To investigate the rate and predictive factors of post-operative neurological deterioration in ossified yellow ligament (OYL) surgery.

METHODS

A retrospective review was conducted for all patients with thoracic OYL causing myelopathy requiring surgical decompression from January 1998 to December 2012. Clinical parameters under study included clinical presentation, distribution of OYL, pre-operative walking score, pre- and post-operative neurological status, status of intra-operative neurophysiological monitoring, and modified Japanese Orthopaedic Association (mJOA) score. Any complications were also recorded. All outcomes were measured at post-operative 1 week and at 2 years.

RESULTS

A total of 26 patients were included in this study. Most patients (92.3%) had Frankel grade D pre-operatively. The rate of neurological deterioration was 15.4% and was correlated with the presence of dural tear, extra-dural hematoma and spinal cord injury. Pre-operative walking score was prognostic of patients' walking ability in the post-operative period. Intra-operative monitoring of Somatosensory Evoked Potentials (SSEP) was found to be useful for monitoring spinal cord injury in OYL surgery, with a positive predictive value of 100% and a negative predictive value of 92.3%. The false negative rate of a SSEP signal drop was only 7.7% CONCLUSIONS: This is the first study exploring risk factors for post-operative neurological deterioration after surgery for thoracic OYL. The rate of neurological deficit is not small and prognostic factors for poor outcome include poor pre-operative walking score, presence of intra-operative dural tear, extra-dural hematoma and spinal cord injury, and intra-operative drop of SSEP signal.

Case report: severe bradycardia, a reversible cause of "Cardio-Renal-Cerebral Syndrome"

Background

Cardio-Renal Syndromes were first classified in 2008 and divided into five subtypes. The type 1 Cardio-Renal Syndrome (CRS) is characterized by acute decompensation of heart failure leading to acute kidney injury (AKI). Bradyarrhythmia was not mentioned in the classification as a cause for low cardiac output (CO) in type 1 CRS. Besides, CRS was not previously associated with central nervous system (CNS) injury despite the fact that cardiac, renal and neurological diseases can coexist.

Case presentation

We report the case of a 93-year old diabetic man who presented for obnubilation. He had a slow atrial fibrillation, was not hypotensive and was not taking any beta-blocker. He developed, simultaneously, during his hospitalization, severe bradycardia (<35 beats per minute), oligoanuria and further neurological deterioration without profound hypotension. An ECG revealed a complete atrioventricular (AV) block and all his symptoms were completely reversed after pacemaker insertion. His creatinine decreased progressively afterwards and at discharge, he was conscious, alert and well oriented.

Conclusion

Our case highlights the importance of an early recognition of low cardiac output secondary to severe bradyarrhythmia and its concurrent repercussion on the kidney and the brain. This association of the CRS with CNS injury-that we called “Cardio-Renal-Cerebral Syndrome”–was successfully treated with permanent pacemaker implantation.

Statin and Aspirin Pretreatment Are Associated with Lower Neurological Deterioration and Platelet Activity in Patients with Acute Ischemic Stroke

BACKGROUND

Aspirin and statin are recommended for the treatment of acute ischemic stroke. However, whether aspirin and statin pretreatment is associated with clinical outcomes has not been well addressed. This study aimed to evaluate the effect of pre-existing statin and aspirin use on platelet activation and clinical outcome in acute ischemic stroke patients.

METHODS

We conducted a prospective, multicenter observational study in patients with acute ischemic stroke. Platelet aggregation and platelet-leukocyte aggregates were measured on admission and during 7-10 days after admission. The primary outcome of the study was neurological deterioration (ND) within 10 days after admission. The secondary outcome was a composite of recurrent ischemic stroke, myocardial infarction, and death during the first 3 months after admission. Physical disability was evaluated using the modified Rankin Scale score at 3 months after admission.

RESULTS

Among 1124 enrolled patients, 270 (24%) experienced ND. Higher platelet aggregation and platelet-leukocyte aggregates on admission and during 7-10 days were associated with ND. Platelet aggregation and platelet-leukocyte aggregates on admission were significantly lower in the patients with pre-existing statin or aspirin use than those without treatment. Patients with prestroke concomitant statin and aspirin treatment had significantly lower incidence of ND than those without treatment. Diabetes mellitus, fasting glucose, platelet-leukocyte aggregates, and prestroke concomitant statin and aspirin use were independently associated with ND.

CONCLUSIONS

Prestroke concomitant statin and aspirin use is associated with lower neurological deterioration and platelet activity in patients with acute ischemic stroke.

Antiplatelet drug resistance is associated with early neurological deterioration in acute minor ischemic stroke in the Chinese population

To evaluate the prevalence and risk factors of antiplatelet drug resistance and its association with early neurological deterioration (END) and recurrent ischemic stroke (RIS) in patients with acute minor stroke. Antiplatelet drug resistance was assessed by platelet aggregation assay in 426 patients with minor stroke who were receiving combined treatment of aspirin and clopidogrel. All patients were followed up for 90 days. The primary endpoint of the study was END within 10 days after admission. The secondary endpoints included RIS, myocardial infarction and death during 90 days of treatment. The safety endpoints were intracerebral or extracranial hemorrhagic events. Cox proportional hazard regression analysis was performed to determine the risk factors for the primary endpoint and secondary endpoints. Among the 426 patients, 24.4 % exhibited aspirin resistance, 35.9 % exhibited clopidogrel resistance, and 19.2 % displayed concomitant aspirin and clopidogrel resistance. In multivariate analysis, diabetes mellitus and high level of low density lipoprotein-cholesterol were independent risk factors for aspirin resistance, while diabetes mellitus was the only independent risk factor for clopidogrel resistance. END was observed in 93 (21.8 %) patients. Diabetes mellitus, high fasting blood glucose level, and concomitant aspirin and clopidogrel resistance were independent risk factors for END. RIS was observed in 40 (9.4 %) patients. Diabetes mellitus, hypertension, and concomitant aspirin and clopidogrel resistance were independent risk factors for RIS. Antiplatelet drug resistance is common in acute minor ischemic stroke patients and is associated with END and RIS after acute minor ischemic stroke in the Chinese population.

CLINICAL TRIAL REGISTRATION INFORMATION

http://www.chictr.org/ . Unique Identifier: ChiCTR-OCH-14004724.

Early neurological worsening in patients with Wilson's disease

BACKGROUND

Early neurological worsening during treatment initiation for Wilson's disease (WD) is an unresolved problem. Our aim was to establish the frequency and outcome of early neurological worsening in patients with WD.

METHODS

We analyzed 143 symptomatic patients diagnosed with WD between 2005 and 2009. Early neurological deterioration was based on worsening on the Unified Wilson's Disease Score Scale, scored at baseline through 6 months or occurrence of new neurological symptoms. Reversibility of worsening was followed up to 24 months.

RESULTS

Early neurological worsening was observed in 11.1% (16/143) and involved only patients with neurological signs at diagnosis. Mean time to worsening from treatment initiation was 2.3 ± 1.9 months. Neurological deterioration was completely reversible in 53% (8/15) and partially in 13% (2/15) of patients over 9.2 ± 5.2 months. Patients who experienced early deterioration had significantly more severe baseline neurological deficit, higher prevalence of thalamic (66% vs 29%) and brain stem (73% vs 33%) lesions seen on baseline magnetic resonance imaging, and more often used concomitant dopamine receptor antagonists (46% vs 5%). Disease duration, treatment type (d-penicillamine or zinc sulfate), type of neurological manifestations, initial copper metabolism results, and liver function parameters did not differ between evaluated groups.

CONCLUSIONS

Neurological worsening at the beginning of anti-copper therapy may occur in over 10% of WD patients. Special attention should be paid to those with severe initial neurological manifestations, advanced brain injury and using dopamine receptor antagonists. Type of anti-copper therapy did not show clear association with early neurological worsening.

Adult phenylketonuria presenting with subacute severe neurologic symptoms

We report a 48-year-old Japanese woman with phenylketonuria (PKU) who presented with severe neurological symptoms more than 30 years after discontinuation of dietary treatment. She was diagnosed with PKU at 6-years-old and was treated with a phenylalanine restricted diet until she was 15 years old. When she was 48-years-old she started having difficulty walking. After several months, she presented with severe disturbance of consciousness and was admitted. She was diagnosed as having neurological complications associated with PKU. We observed temporal changes in her laboratory data, brain MRI and single-photon emission computed tomography (SPECT) scan findings. Brain MRI on T2-weighted, fluid-attenuated inversion recovery and diffusion-weighted images revealed high intensity lesions in her bilateral frontal lobes and 123I-IMP SPECT showed marked and diffuse hypoperfusion in the bilateral cerebrum and cerebellum. After the resumption of dietary treatment, serum phenylalanine concentrations immediately decreased to the normal range. However, her neurological symptoms took longer to improve. We also found no clear temporal association between MRI findings and clinical severity. SPECT abnormalities showed marked improvement after treatment. It is well known that PKU patients who discontinue the dietary restriction from their childhood develop minor neurological impairments. However, PKU patients with late-onset severe neurological symptoms are very rare. To our knowledge, this is the first report regarding SPECT findings of PKU patients with late-onset severe neurological deterioration.

Analysis of the prevalence and distribution of cervical and thoracic compressive lesions of the spinal cord in lumbar degenerative disease

STUDY DESIGN

Retrospective study.

PURPOSE

The aim of the present study is to analyze the prevalence and distribution of cervical and thoracic compressive lesions of the spinal cord in lumbar degenerative disease, using whole-spine postmyelographic computed tomography.

OVERVIEW OF LITERATURE

Of the various complications resulting from spinal surgery, unexpected neurological deterioration is the most undesired. There are reports of missed compressive lesions of the spinal cord at the cervical or thoracic level in lumbar degenerative disease.

METHODS

There were 145 consecutive patients with symptomatic lumbar degenerative disease evaluated. Before the lumbar surgery, image data were obtained. The following parameters at the cervical and thoracic levels were analyzed: compressive lesions from the anterior parts; compressive lesions from the anterior and posterior parts; ossification of the ligamentum flavum; ossification of the posterior longitudinal ligament; and spinal cord tumor.

RESULTS

Compressive lesions from the anterior parts were observed in 34 cases (23.4%). Compressive lesions from the anterior and posterior parts were observed in 34 cases (23.4%). Lesions of ossification of the ligamentum flavum were observed in 45 cases (31.0%). Lesions of ossification of the posterior longitudinal ligament were observed in 15 cases (10.3%). Spinal cord tumor was not observed.

CONCLUSIONS

A survey of compressive lesions at the cervical or thoracic level in lumbar degenerative disease is important in preventing unexpected neurological deterioration after the lumbar surgery.

Surgical treatment of lumbar hyperextension injury in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic systemic and inflammatory rheumatic disease with a variable course of the axial skeleton. Spinal involvement may accompany ossification of the ligaments, intervertebral disc, end-plates and apophyseal structures, and seems to be "bamboo spine". Because of these natures of the spine in AS, a spinal fracture can be occurred with minor trauma or spontaneously. The fracture of the AS can cause neurological complications extremely high, so special attention to prevent neurological deterioration. Operative management of the injured spine with AS is difficult, and associated with a high complication rate. Extreme care must be taken for surgery to prevent secondary neurological deterioration.

Subacute Neurological Deterioration with Selective Axonal Injury in Patients with Acute Ischemic Stroke following Reperfusion of Middle Cerebral Artery Occlusion

To date, the long-term effects of reperfusion on the salvaged brain tissues have not been addressed in the literature. We report 4 cases presenting subacute neurological deteriorations with selective axonal injury following reperfusion therapies for acute ischemic stroke. Our case series based on 4 patients showed common features distinct from those of early reperfusion injury in that (1) the neurological symptoms developed after 1-2 months of reperfusion therapies, (2) these symptoms were accompanied by the subcortical white matter changes on brain MRI, and (3) these findings were mostly reversible with time. This suggests that axons in the reperfused brain may be vulnerable to further neurological injury.

Rapid Atypical Progression of Neuro-Behçet's Disease Involving Whole Brainstem and Bilateral Thalami

We present a case of Neuro-Behçet's disease with an unpredictable clinical course. A 47-year-old man was admitted to the neurosurgery department of our hospital with a mild headache. Three days after admission, his consciousness suddenly decreased and respiratory distress progressed rapidly. A brain MRI revealed that the previously observed abnormal signal had extended markedly to both the thalamic areas and the entire brain stem, and the surrounding brain parenchyma were compressed by cerebral edema. Based on the patient's symptoms of recurrent oral and genital ulcers, skin lesions, and uveitis, a rheumatologist made a diagnosis of Behçet's disease with CNS involvement. The patient was treated with high-dose methylprednisolone with respiratory assistance in the intensive care unit for 9 days and his neurologic symptoms improved remarkably. Neuro-Behçet's disease must be considered in the differential diagnosis in rapidly deteriorated young neurological patients along with a stroke, low-grade glioma, multiple sclerosis, and occlusive venous disease.