Search

Neurologic deficits appearing after various anesthetic techniques are not always caused by these procedures, also some are attributed to them. Neuraxial blocks - spinal, more often than epidural - have been associated with the postoperative relapse of multiple sclerosis, although the evidence is not strong. The mechanism is unknown but it is speculated that the disease makes the spinal cord more susceptible to the neurotoxic effects of local anesthetics. We present the case of 42-years-old female, scheduled for ureteroscopy for ureteric calculi under spinal anesthesia. Postoperatively she developed various neurological symptoms that together with the paraclinical findings led to the diagnosis of multiple sclerosis. [ABSTRACT FROM AUTHOR]

Background: Intravenous tissue plasminogen activator (IV tPA) improves neurologic outcome after stroke, but is not recommended for patients with minor neurologic deficits commonly classified by a lower cutoff on the National Institutes of Health Stroke Scale (NIHSS). Because not all stroke signs are captured on the NIHSS, the use of a strict cutoff may exclude functionally impaired stroke patients from IV tPA treatment. Methods: We described functional impairment, safety, and clinical outcome in patients derived from our hospital thrombolysis database who had stroke that was considered disabling despite a neurologic deficit that was considered mild. We used 2 cutoffs: NIHSS score ≤4 and ≤3. Functional impairment was assessed with the modified Rankin Scale (mRS). Results: Between 2008 and 2011, a total of 670 acute ischemic stroke patients received IV tPA in our institution. 107 (16%) of these patients presented with a NIHSS score ≤4; 65 (10%) patients presented with a NIHSS score ≤3. All of these patients were considered functionally impaired (mRS score ≥2). The most frequent symptoms were language impairment (two-thirds), distal (hand) paresis (one-third), and gait disorder in both groups. Symptomatic intracerebral hemorrhage occurred in 1 patient with a NIHSS score of 4 (1%). Despite IV tPA therapy, 26% had a nonfavorable outcome (mRS score 0-1) after 3 months, and 52% had persisting symptoms in both groups. Conclusions: Language impairment, distal (hand) paresis, and gait disorder are common disabling deficits in patients with low NIHSS scores. Judgment of whether a stroke is disabling should not be based on the NIHSS score but on the assessment of the individual neurologic deficits and their impact on functional impairment. [Copyright &y& Elsevier]

Purpose: To report morphological patterns of osteoporotic vertebral compression fractures (OVCFs) presenting for surgery. To describe surgical options based on fracture pattern. To evaluate clinical and radiological outcome. Methods: Forty consecutively operated OVCFs nonunion patients were retrospectively studied. We define four patterns of OVCFs that needed surgical intervention. Group 1 mini open vertebroplasty ( N = 10) no neurologic deficits and kyphotic deformity, but with intravertebral instability and significant radiological spinal canal compromise. Group 2 with neurologic deficits ( N = 24) (2A)-transpedicular decompression (TPD) with instrumentation ( N = 14). Fracture morphology similar to (1) and localized kyphosis <30° (2B)-pedicle subtraction osteotomy (PSO) with instrumentation ( N = 10). Fracture morphology similar to (1) and local kyphosis >30°. Group 3 posterolateral decompression with interbody reconstruction ( N = 06) endplate(s) destroyed, with instability at discovertebral junction, with neurologic deficit. Average follow-up was 34 months. VAS, ODI and Cobb angle were recorded at 3, 6, 12 months and yearly. Results: There was significant improvement in the clinical (VAS and ODI) scores and radiologic outcome in each group at last follow-up. 30 patients out of 40, had neurologic deficits (Frankel's grade C = 16, Frankel's grade D = 14). The motor power gradually improved to Frankel's grade E. Average duration of surgery was 97 min. Average blood loss was 610 ml. Conclusion: Different surgical techniques were used to suit different fracture patterns, with good clinical and radiological results. This could be a step forward in devising an algorithm to surgical treatment of OVCF nonunions. [ABSTRACT FROM AUTHOR]

Objective: To identify the specific angioarchitectural characteristics of arteriovenous malformations (AVMs) that are associated with a clinical presentation of nonhemorrhagic neurologic deficits. Methods: Between 1999 and 2008, 302 consecutive patients with AVMs were referred to our institution. Twenty-four patients (7.9%) presented with neurologic deficits without hemorrhage before treatment. We tested for statistical associations between angioarchitectural characteristics and neurological deficits at presentation. Results: When we compared the 24 (7.9%) patients with nonhemorrhagic neurological deficits with the 278 patients who did not experience neurologic deficits initially (total of 302 patients), female sex (P = 0.002), deep AVM location (P = 0.015), AVM size greater than 3 cm (P = 0.001), more than three arterial feeders present (P = 0.004), only perforating feeding artery (P = 0.007), the presence of more than three draining veins (P = 0.016), the presence of varices in the venous drainage (P = 0.013), and a Spetzler-Martin grade of III to V (P = 0.004) were statistically associated with neurological deficits. Patient age, eloquent location, deep venous drainage, venous drainage restriction, and coexisting aneurysms were not statistically associated with neurological deficits without hemorrhage. Conclusion: The characteristics of AVM associated with nonhemorrhagic neurological deficits include female sex, deep AVM location, more than three arterial feeders, only perforating feeding artery, more than three draining veins, the presence of varices in the venous drainage, and a Spetzler-Martin grade of III to V. [Copyright &y& Elsevier]

Purpose: High-grade C1C2 luxation is a rare pathology. There is no clear evidence as to how to treat this deformity. There is only limited evidence about the different surgical techniques and possible approaches including advantages, disadvantages, and complications. Methods: This is an uncommon case of a 13-year-old child with progressive, tetraplegia due to congenital os odontoideum with translational instability between C1 and C2, and progressive luxation of C2. An irreducible dislocation of the C0/C1 complex caused significant compression at the cervicomedullary junction and neurologic deficit. In this paper we highlight the different types of os odontoideum, a review of existing evidence of surgical correction. We will discuss the different treatment strategies which could be applied and the current solution will be described. Results: Continuous skeletal traction and translational reduction was achieved by a specially designed halo traction system including continuous skeletal traction in a wheelchair for 6 weeks. The surgical treatment consisted of a posterior only release, translational reduction and posterior instrumentation from C0 to C4 with a Y plate and homologous bone graft. Neurological deficits started to improve during halo traction. After surgery the patient was ambulatory without any assistance and reached a Frankel stage E. Postoperative X-rays and CT scan revealed complete reduction at the C1/C2 level and a decompressed cervicomedullary junction. Conclusion: Treatment of severe C1C2 luxation is difficult with limited evidence in the literature. The current case shows a successful treatment strategy to reduce the deformity and lists alternative approaches.[Figure not available: see fulltext.] [ABSTRACT FROM AUTHOR]

Purpose: Evidence-based guidelines do not indicate when ventricular reservoirs should be placed in children with neonatal hydrocephalus, and delayed intervention is common. We hypothesize that delayed ventricular drainage has adverse effects on structural development and functional outcomes. Methods: Using a well-established animal model of kaolin-induced obstructive hydrocephalus, we evaluated neurologic deficit after early (~1 week post-kaolin) or late (~2 weeks post-kaolin) placement of ventricular reservoirs which were tapped according to strict neurologic criteria. Results: Progressive ventriculomegaly was similar in early- and late-reservoir implantation groups. The average neurologic deficit scores (NDSs) over the experimental period were 0 ( n = 6), 2.74 ( n = 5), and 2.01 ( n = 3) for the control, early-, and late-reservoir groups, respectively. At reservoir placement, early-group animals displayed enlarged ventricles without neurologic deficits (mean NDS = 0.17), while the late group displayed ventriculomegaly with clinical signs of hydrocephalus (mean NDS = 3.13). The correlation between ventriculomegaly severity and NDS in the early group was strongly positive in the acute (before surgery to 3 weeks post-reservoir placement) ( R = 0.65) and chronic (6 to 12 weeks post-reservoir placement) ( R = 0.65) phases, while the late group was less correlated (acute R = 0.51; chronic R = 0.19). Conclusions: Current practice favors delaying reservoir implantation until signs of elevated intracranial pressure and neurologic deficit appear. Our results demonstrate that animals in early and late groups undergo the same course of ventriculomegaly. The findings also show that tapping reservoirs in these neonatal hydrocephalic animals based on neurologic deficit does not halt progressive ventricular enlargement and that neurologic deficit correlates strongly with ventricular enlargement. [ABSTRACT FROM AUTHOR]

The aim of this study was to clarify changes in the lactate threshold (LT) in the acute period after cerebral infarction. Cerebral infarction was induced by the injection of microspheres (MS) into the right internal carotid artery. To estimate the degree of neurologic deficit caused by surgery, the behaviors of all rats were evaluated in terms of typical symptoms of stroke in rats. The rotarod test was used to evaluate equilibrium function. Rats were forced to perform stepwise treadmill exercises, and serial changes in blood lactate concentration were measured for determination of the LT. The average treadmill speed at the LT and the rotarod test performance in MS rats was significantly lower than those in sham-operated rats on postsurgery day 2. However, although neurologic deficits disappeared on postsurgery day 7 in MS rats, LT level and rotarod test performance were significantly lower than in sham-operated rats. These results suggest that the decrease in LT in the acute period after cerebral infarction might be induced by impaired equilibrium function. Other possibilities are discussed as well. [Copyright &y& Elsevier]

Purpose: Lateral lumbar interbody fusion (LLIF) is a minimally invasive technique that has gained growing interest in recent years. We performed a retrospective review of the medical records and operative reports of patients undergoing LLIF between March 2006 and December 2009. We seek to identify the incidence and nature of neurological deficits following LLIF. Methods: New occurring sensory and motor deficits were recorded at 6 and 12 weeks as well as 6- and 12 months of follow-up. Motor deficits were grouped according to the muscle weakness and severity and sensory deficits to the dermatomal zone. New events were correlated to the patient demographics, pre-operative diagnosis, operative levels, and duration of surgery. At each post-operative time-point patients were queried regarding the presence of leg pain. Results: A total of 235 patients (139 F; 96 M) with a total of 444 levels fused were included. Average age was 61.5 and mean BMI 28.3. At 12 months' follow-up, the prevalence of sensory deficits was 1.6%, psoas mechanical deficit was 1.6% and lumbar plexus related deficits 2.9%. Although there was no significant correlation between the surgical level L4-5 and an increased psoas mechanical flexion or lumbar plexus related motor deficit, a trend was observed. Independent risk factors for both psoas mechanical hip flexion deficit and lumbar plexus related motor deficit was duration of surgery. Conclusion: LLIF is a valuable tool for achieving fusion through a minimally invasive approach with little risk to neurovascular structures. [ABSTRACT FROM AUTHOR]

Although inflammatory responses increase stroke severity, the role of immune cells specific for central nervous system (CNS) antigens remains controversial. Disruption of the blood-brain barrier (BBB) during stroke allows CNS antigens to leak into the peripheral circulation and enhances access of circulating leukocytes to the brain, including those specific for CNS antigens such as myelin oligodendrocyte glycoprotein (MOG) that can induce experimental autoimmune encephalomyelitis (EAE). We here demonstrate for the first time that myelin reactive splenocytes specific for MOG transferred into severe combined immunodeficient (SCID) mice can migrate into the infarct hemisphere of recipients subjected to 60 min middle cerebral artery occlusion (MCAO) and 96 h reperfusion; moreover these cells exacerbate infarct volume and worsen neurological deficits compared to animals transferred with naïve splenocytes. These findings indicate that autoimmunity in the CNS can exert detrimental injury on brain cells and worsen the damage from ischemic stroke. [ABSTRACT FROM AUTHOR]

Purpose: We report our experience and literature review concerning surgical treatment of neurological burst fractures of the fifth lumbar vertebra. Materials and methods: Nineteen patients with L5 neurological burst fractures were consecutively enrolled; 6 patients had complete motor deficits, and 12 had sphincter dysfunction. We performed 18 posterior and one combined approaches. To avoid kyphosis, posterior internal fixation was achieved by positioning patients on the operating table with hips and knees fully extended. At the latest follow-up (mean 22 months, range 10-66), neurological recovery, canal remodeling and L4-S1 angle were evaluated. Results: Vertebral body replacement was difficult, which therefore resulted in an oblique position of the cage. Vertebral bodies still remained deformed, even though fixation allowed for an acceptable profile (22°, range 20-35). We observed three cases of paralysis, five complete, and three incomplete recoveries. In the remaining eight patients, sphincter impairment was the only finding. In 15 patients, pain was absent or occasional; in four individuals, it was continuous but not invalidating. Remodeling was visible by X-ray and/or CT, without significant secondary stenosis. Conclusions: The L5 burst fractures are rare and mostly due to axial compression. Cauda and/or nerve root injuries are absolute indications for surgery. If an anterior approach is technically difficult, laminectomy can allow for decompression, and it can be easily combined with transpedicular screw fixation. Posterior instrumented fusion, also performed with the aim to restore sagittal profile, when associated with an accurate spinal canal exploration and decompression, may be looked at as an optimal treatment for neurological L5 burst fractures. [ABSTRACT FROM AUTHOR]

Objective. To assess differences of fetal behavior in normal and high-risk pregnancies. Methods. In the 1-year period (1 January 2007--31 December 2007), four-dimensional ultrasound has been used to assess Kurjak antenatal neurodevelopmental test (KANET) in low- and high-risk pregnancies after randomization in prospective longitudinal cohort study. Based on the KANET scores, the fetuses were considered as normal (≥≥14 points), borderline (6--13), or abnormal (0--5). Results. Comparison of KANET scores in low- and high-risk pregnancies were expectedly statistically significant. The largest incidence of fetuses with abnormal KANET was in the group of fetuses who had siblings with cerebral palsy. The largest incidence of the borderline KANET has been found in the group of fetuses whose mothers had fever during pregnancy. The following parameters of KANET test significantly differed between the fetuses from low- and high-risk pregnancies: overlapping cranial sutures, head circumference, isolated eye blinking, facial expressions, mouth movements, isolated hand movements, isolated leg movements, hand to face movement, finger movements, and general movements. Conclusion. KANET test has the potential to detect and discriminate normal from borderline and abnormal fetal behavior in normal and in high-risk pregnancies. [ABSTRACT FROM AUTHOR]

In this case report, we present prenatal and postnatal neurological evaluation of a fetus and newborn from pregnancy complicated with intrauterine growth restriction, fetal hypoxemia, and preterm labor. Despite unfavorable intrauterine conditions, this premature infant showed normal early neurological development that was verified not only by postnatal tests but also with a new prenatal neurological screening test. [ABSTRACT FROM AUTHOR]

[Figure not available: see fulltext.]A primary Echinococcus granulosus infection of the spine involving the vertebrae T8 and T9 of a 6-year-old child was treated elsewhere by thoracotomy, partial corporectomy, multiple laminectomies and uninstrumented fusion. Owing to inappropriate stabilization, severe deformity developed secondary to these surgeries. X-rays, CT and MRI scans of the spine revealed a severe thoracic kyphoscoliosis of more than 100° (Fig. 1) and recurrence of Echinococcus granulosus infection. The intraspinal cyst formation was located between the stretched dural sac and the vertebral bodies of the kyphotic apex causing significant compression of the cord (Figs. 2, 3, 4). A progressive neurologic deficit was reported by the patient. At the time of referral, the patient was wheelchair bound and unable to walk by herself (Frankel Grade C). Standard antiinfectious therapy of Echinococcus granulosus requires a minimum treatment period of 3 months. This should be done before any surgical intervention because in case of a rupture of an active cyst, the delivered lipoprotein antigens of the parasite may cause a potentially lethal anaphylactic shock. Owing to the critical neurological status, we decided to perform surgery without full length preoperative antiinfectious therapy. Surgical treatment consisted in posterior vertebral column resection technique with an extensive bilateral costotransversectomy over three levels, re-decompression with cyst excision around the apex and multilevel corporectomy of the apex of the deformity. Stabilisation and correction of the spinal deformity were done by insertion of a vertebral body replacement cage anteriorly and posterior shortening by compression and by a multisegmental pedicle screw construct. After the surgery, antihelminthic therapy was continued. The patients neurological deficits resolved quickly: 4 weeks after surgery, the patient had Frankel Grade D and was ambulatory without any assistance. After an 18-month follow-up, the patient is free of recurrence of infection and free of neurologically deficits (Frankel E). This case demonstrates that inappropriate treatment—partial resection of the cyst, inappropriate anterior stabilization and posterior multilevel laminectomies without posterior stabilization—may lead to severe progressive kyphoscoliotic deformity and recurrence of infection, both leading to significant neurological injury presenting as a very difficult to treat pathology.[Figure not available: see fulltext.][Figure not available: see fulltext.][Figure not available: see fulltext.][Figure not available: see fulltext.] [ABSTRACT FROM AUTHOR]

BACKGROUND: As the tumor spreads through the pathway of least resistance, the present study was carried out to evaluate the presence of perineural infiltration and spread of oral squamous cell carcinoma (OSCC) along the perineural spaces in gingivobuccal sulcus tumors infiltrating into the mandible. AIMS AND OBJECTIVES: (1) To investigate the incidence of perineural invasion of OSCC along the inferior alveolar nerve and (2) to investigate the neurovascular bundle as a potential route of spread of OSCC. MATERIALS AND METHODS: Twenty–six patients with histopathologically proven OSCC of the gingivobuccal sulcus with radiographic infiltration of the mandible were included. The surgical specimens were decalcified and serially sectioned. Each section was stained with hematoxylin and eosin and was screened for the presence of perineural invasion and spread. RESULTS: Twenty–five specimens showed perineural infiltration but none of the cases showed perineural spread along the inferior alveolar canal. Also, not all cases showed any neurologic deficit. Follow–up of these cases showed early recurrence (6–8 months) in the study group. CONCLUSION: Perineural infiltration is present in OSCC but perineural spread along the inferior alveolar canal is absent. It is a bad prognostic indicator. [ABSTRACT FROM AUTHOR]

Motor vehicle collision (MVC) is one of the most common causes of thoracolumbar junction (TLJ) injury. Although it is of no doubt that the use of seatbelt reduces the incidence and severity of MVC-induced TLJ injury, how it is protective for front-seat occupants of an automobile after rollover crashes is unclear. Among 200 consecutive patients with a major TLJ (Th11-L2) injury due to high-energy trauma admitted from 2000 to 2004, 22 patients were identified as front-seat occupants of a four-wheel vehicle when a rollover crash occurred. The 22 patients were divided into two groups: 10 who were belted, and 12 who were unbelted. Patients’ demographics including the mean Injury Severity Score (ISS), incidence of neurologic deficit, level of TLJ injury, and type of TLJ injury according to the AO fracture classification were compared between the two groups. Neurologic deficit was present exclusively in the unbelted group, and the difference in the incidence was statistically significant ( P = 0.04). Similarly, AO type B/C injury was present exclusively in the unbelted group. The belted group had a significantly lower mean ISS than the unbelted group ( P < 0.01). Comparison between the ejected and non-ejected victims within the unbelted group revealed no statistical difference in the incidence of neurologic deficit or type of injury. It is likely that the high incidence of neurologic deficit in the unbelted group was due to the high incidence of AO type B/C injury. This study indirectly proves the efficacy of seatbelt in reducing the severity of rollover-induced TLJ injury. Because of the limited number of cases, it is uncertain whether ejection from vehicle, which occurs exclusively in the unbelted victims, is a crucial factor in determining the severity or type of injury after rollover crashes. [ABSTRACT FROM AUTHOR]

Primate models are essential tools for translational research in stroke but are reportedly inconsistent in their ability to produce cortical infarcts of reproducible size. Here, we report a new stroke model using a transorbital, reversible, two-vessel occlusion approach in male rhesus macaques that produces consistent and reproducible cortical infarcts. The right middle cerebral artery (distal to the orbitofrontal branch) and both anterior cerebral arteries were occluded with vascular clips. Bilateral occlusion of the anterior cerebral artery was critical for reducing collateral flow to the ipsilateral cortex. Reversible ischemia was induced for 45, 60, or 90 mins (n=2/timepoint) and infarct volume and neurologic outcome were evaluated. The infarcts were located predominantly in the cortex and increased in size with extended duration of ischemia determined by T2-weighted magnetic resonance imaging . Infarct volume measured by 2,3,5-triphenyl tetrazolium chloride and cresyl violet staining corroborated magnetic resonance imaging results. Neurologic deficit scores worsened gradually with longer occlusion times. A subset of animals (n=5) underwent 60 mins of ischemia resulting in consistent infarct volumes primarily located to the cortex that correlated well with neurologic deficit scores. This approach offers promise for evaluating therapeutic interventions in stroke.Journal of Cerebral Blood Flow & Metabolism (2009) 29, 1175–1186; doi:10.1038/jcbfm.2009.43; published online 22 April 2009 [ABSTRACT FROM AUTHOR]

The primary objective of this nationwide survey carried out in department of cardiac anesthesia in Germany was to identify current practice with regard to neuromonitoring und neuroprotection. The data are based on a questionnaire sent out to all departments of cardiac anesthesia in Germany between October 2007 und January 2008. The anonymized questionnaire contained 26 questions about the practice of preoperative evaluation of cerebral vessels, intra-operative use of neuromonitoring, the nature und application of cerebral protective measures, perfusion management during cardiopulmonary bypass, postoperative evaluation of neurological status, and training in the field of cerebral monitoring. Of the 80 mailed questionnaires 55% were returned and 90% of department evaluated cerebral vessels preoperatively with duplex ultrasound. The methods used for intra-operative neuromonitoring are electroencephalography (EEG, 60%) for type A dissections (38.1%), for elective surgery on the thoracic and thoraco-abdominal aorta (34.1% and 31.6%, respectively) and in carotid surgery (43.2%) near infrared spectroscopy (40%), evoked potentials (30%) and transcranial Doppler sonography (17.5%), with some centers using combined methods. In most departments the central nervous system is not subjected to monitoring during bypass surgery, heart valve surgery, or minimally invasive surgery. Cerebral protective measures used comprise patient cooling on cardio-pulmonary bypass (CPB 100%), extracorporeal cooling of the head (65%) and the administration of corticosteroids (58%), barbiturates (50%) and antiepileptic drugs (10%). Neuroprotective anesthesia consists of administering inhalation anesthetics (32.5%; sevoflurane 76.5%) and intravenous anesthesia (20%; propofol and barbiturates each accounting for 46.2%). Of the departments 72.5% cool patients as a standard procedure for surgery involving cardiovascular arrest and 37.5% during all surgery using CPB. In 84.6% of department CPB flow equals calculated cardiac output (CO) under normothermia, while the desired mean arterial pressure (MAP) varies between 60 and 70 mmHg (43.9%) and between 50 and 60 mmHg (41.5%), respectively. At body temperatures less than 18°C CPB flow is reduced below the calculated CO (70%) while 27% of departments use normothermic flow rates. The preferred MAP under hypothermia is between 50 and 60 mmHg (59%). The results of intra-operative neuromonitoring are documented on the anesthesia record (77%). In 42.5% of the departments postoperative neurological function is estimated by the anesthesiologist. Continuing education sessions pertaining to neuromonitoring are organized on a regular basis in 32.5% of the departments and in 37.5% individual physicians are responsible for their own neuromonitoring education. The present survey data indicate that neuromonitoring and neuroprotective therapy during CPB is not standardized in cardiac anesthesiology departments in Germany. The systemic use of available methods to implement multimodal neuromonitoring would be desirable. [ABSTRACT FROM AUTHOR]

The article presents the study which examines the effects of hypertonic/hyperoncotic treatment (HHT) and surgical evacuation on acute subdural hematoma (ASDH). Using rat as a model, researchers have explored the acute effects of HHT on blood variables as well as its chronic effects. Results show that HHT has caused in a decrease of intracranial pressure (ICP) after ASDH.

The article evaluates the intraoperative and postoperative complications of lumbar pedicle subtraction osteotomy (PSO). A total of 108 consecutive patients treated with a lumbar PSO at one institution over a ten-year period were analyzed. Based on the results, the study showed that intraoperative or postoperative neurologic deficits were relatively common following a PSO.

Abstract: Background: Tentorial dural arteriovenous fistula is uncommon but is a life-threatening lesion. We present our experience with 5 patients with TDAVFs, review the relevant literature, and present the rationale of our current management strategy. Method: The data of 5 patients with TDAVFs treated in Huashan Hospital, Shanghai, China, between June 2002 and May 2003 were reviewed retrospectively, including their illness history, neuroimaging, operation records, and follow-up data. Results: There were 3 females and 2 males with ages from 25 to 52 years (average, 38 years). Clinical manifestations were acute SAH in 2 patients and progressive neurologic deficits in 3 patients. Magnetic resonance imaging and DSA were major diagnostic and follow-up modalities. All cases belonged to Borden classification type 3. A tentorial marginal type was present in 3 cases, a tentorial lateral type in 1 case, and a tentorial medial type in 1 case. Preoperative transarterial embolization was done in 3 patients. All patients underwent craniotomy with the coagulation of the fistulas and surrounding tentorial dura mater, and the disconnection of leptomeningeal venous drainage. The surgical approaches were via transanterior petrous approach in 3 cases, subtemporal intradural approach in 1 case, and unilateral occipital and transtentorial approach in 1 case. All patients had clinical improvement. There was no surgical mortality and morbidity. Postoperative DSA confirmed obliteration of TDAVFs in 3 cases; MRI demonstrated the thrombosis of venous aneurysm and disappearance of previous brainstem edema in 1 case, and partial thrombosis of venous aneurysm in another case. Follow-up study ranging from 2 to 3 years (average, 2.5 years) showed no recurrence, and all patients have resumed their normal activities. Conclusions: Tentorial dural arteriovenous fistulas are aggressive vascular lesions causing SAH and progressive neurologic deficits. Prompt diagnosis and definite treatment are mandatory. Obliteration of the fistulas and/or leptomeningeal venous drainage should be the goal of treatment. Microsurgical procedures with/without endovascular intervention are the best choice of treatment. [Copyright &y& Elsevier]

Abstract: The embolic MCA occlusion model in rats is used for recanalisation studies in acute stroke. In addition to the determination of lesion size, the assessment of functional outcome may improve the value of this model. Male Wistar rats were submitted to MCA clot embolism or sham surgery. In order to achieve a larger variety of lesion volume, 2 subgroups (each 7 animals) were subjected to differently sized emboli (30 and 40 mm). Follow-up period was 6 days. Outcome assessment consisted of a test battery including parallel bar crossing, observation of behaviour in an open field and an 8-arm maze and a neurological score with ten different sensorimotor and coordinative items. Animals were perfusion-fixed on day 7 (blinded examination). For both subgroups, there were significant impairments with regard to performance on the Neuro score, parallel bar crossing and maze exploration. Improvement was only partial during the follow-up period. On follow-up day 6, there was still a significant correlation between total infarct volume and functional outcome on the Neuro score (R =0.80, p =0.0006) and the exploration behaviour in the maze (R =0.66, p =0.01). Application of emboli with a length of 40 mm caused more functional impairment and a more extended lesion volume compared with 30 mm. We present outcome tests that provide quantitative and objective tools to test functional impairment in rats following embolic stroke. [Copyright &y& Elsevier]

Subarachnoid hemorrhage (SAH) occurs primarily during early to mid-adulthood; approximately 30% of individuals with SAH die within 2 weeks, and mortality is 30% to 45%. SAH happens suddenly, without patients being aware of previous heart abnormalities. Here, we performed a pilot single cohort (historical) study to examine the hypothesis that early abnormal electrocardiographic (ECG) changes may reveal unknown but “silent” heart pathologies in SAH patients without previous heart disease (PHD). Data were collected retrospectively on 56 consecutive patients during the acute phase of SAH (29 men, 27 women; mean age 49.0 ± 6.2 years) with different degrees of neurologic deficit (Hunt-Hess scale assessment) in a 2-year period single-cohort study. Repolarization abnormalities were most frequent (p<0.05) and were independent of a history of PHD, although it corresponded to a higher risk for such abnormalities (odds ratio OR=3.21; CI95%=1.01–10.22). ECG changes in patients without PHD were similar to those in PHD patients, confirming the hypothesis that SAH is associated with previously “silent” heart pathology. The increased frequency of ECG changes in PHD patients and their high incidence in no-PHD patients suggested a neurogenic form of myocardial dysfunction following SAH. Notably, repolarization changes were more frequent in patients with less severe deficit (p<0.05), whereas rhythm and conductive abnormalities were more frequent in patients with more severe neurologic deficit. [ABSTRACT FROM AUTHOR]

Stroke patients have increased levels of endothelin-1 (ET-1), a strong vasoconstrictor, in their plasma or cerebrospinal fluid. Previously, we showed high level of ET-1 mRNA expression in astrocytes after hypoxia/ischemia. It is unclear whether the contribution of ET-1 induction in astrocytes is protective or destructive in cerebral ischemia. Here, we generated a transgenic mouse model that overexpress ET-1 in astrocytes (GET-1) using the glial fibrillary acidic protein promoter to examine the role of astrocytic ET-1 in ischemic stroke by challenging these mice with transient middle cerebral artery occlusion (MCAO). Under normal condition, GET-1 mice showed no abnormality in brain morphology, cerebrovasculature, absolute cerebral blood flow, blood–brain barrier (BBB) integrity, and mean arterial blood pressure. Yet, GET-1 mice subjected to transient MCAO showed more severe neurologic deficits and increased infarct, which were partially normalized by administration of ABT-627 (ETA antagonist) 5 mins after MCAO. In addition, GET-1 brains exhibited more Evans blue extravasation and showed decreased endothelial occludin expression after MCAO, correlating with higher brain water content and increased cerebral edema. Aquaporin 4 expression was also more pronounced in astrocytic end-feet on blood vessels in GET-1 ipsilateral brains. Our current data suggest that astrocytic ET-1 has deleterious effects on water homeostasis, cerebral edema and BBB integrity, which contribute to more severe ischemic brain injury.Journal of Cerebral Blood Flow & Metabolism (2005) 25, 998–1011. doi:10.1038/sj.jcbfm.9600108; published online 30 March 2005 [ABSTRACT FROM AUTHOR]

Copyright of Der Unfallchirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Intensivmedizin und Notfallmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Over the past decade, operative treatment of vertebral burst fractures has become common. To assess the success of closed or open reduction of displaced vertebral spinal fragments, imaging methods such as fluoroscopy, ultrasound and myelography are used. As with every procedure, a number of potential sources of error exist. We report 2 cases with neurologic complications after failed intraoperative myelography. In order to avoid such complications, recommendations for a safe technique are given. We present our method of treating vertebral burst fractures with and without neurologic deficit. [ABSTRACT FROM AUTHOR]

Older patients with pyogenic vertebral osteomyelitis (PVO) usually have more medical comorbidities compared with younger patients, and present with advanced infections from different causative organisms. To aid surgical decision-making, we compared surgical outcomes of older patients with PVO to those who underwent nonoperative treatment. We identified the risk factors for adverse post-operative outcomes, and analyzed the clinical risks from further spinal instrumentation. This retrospective comparative study included 439 patients aged ≥75 years with PVO. Multivariable analysis was performed to compare treatment outcomes among three groups: 194, 130, and 115 patients in the non-operative, non-instrumented, and instrumented groups, respectively. The risk factors for adverse outcomes after surgical treatment were evaluated using a logistic regression model, and the estimates of the multivariable models were internally validated using bootstrap samples. Recurrence and mortality of these patients were closely associated with neurologic deficits, and increased surgical invasiveness, resulting from additional spinal instrumentation, did not increase the risk of recurrence or mortality. We propose that surgical treatment for these patients should focus on improving neurologic deficits through immediate and sufficient removal of abscesses. Spinal instrumentation can be performed if indicated, within reasonable clinical risk. [ABSTRACT FROM AUTHOR]

Background: Globally, 85% of acute kidney injury (AKI) cases occur in low-and-middle-income countries. There is limited information on persistent kidney disease (acute kidney disease [AKD]) following severe malaria-associated AKI., Methods: Between March 28, 2014, and April 18, 2017, 598 children with severe malaria and 118 community children were enrolled in a two-site prospective cohort study in Uganda and followed up for 12 months. The Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to define AKI (primary exposure) and AKD at 1-month follow-up (primary outcome). Plasma neutrophil gelatinase-associated lipocalin (NGAL) was assessed as a structural biomarker of AKI., Findings: The prevalence of AKI was 45·3% with 21·5% of children having unresolved AKI at 24 h. AKI was more common in Eastern Uganda. In-hospital mortality increased across AKI stages from 1·8% in children without AKI to 26·5% with Stage 3 AKI ( p  < 0·0001). Children with a high-risk plasma NGAL test were more likely to have unresolved AKI (OR, 7·00 95% CI 4·16 to 11·76) and die in hospital (OR, 6·02 95% CI 2·83 to 12·81). AKD prevalence was 15·6% at 1-month follow-up with most AKD occurring in Eastern Uganda. Risk factors for AKD included severe/unresolved AKI, blackwater fever, and a high-risk NGAL test (adjusted p  < 0·05). Paracetamol use during hospitalization was associated with reduced AKD ( p  < 0·0001). Survivors with AKD post-AKI had higher post-discharge mortality (17·5%) compared with children without AKD (3·7%)., Interpretation: Children with severe malaria-associated AKI are at risk of AKD and post-discharge mortality., Funding: This work was supported by the National Institutes of Health National Institute of Neurological Disorders and Stroke (R01NS055349 to CCJ) and the Fogarty International Center (D43 TW010928 to CCJ), and a Ralph W. and Grace M. Showalter Young Investigator Award to ALC., Competing Interests: Dr. John reports grants from NIH during the conduct of the study. The other authors declare no competing interests., (© 2022 The Author(s).)

Background: Severe sickle cell disease (SCD) can present with different vaso-occlusive manifestations with cerebral vasculopathy (CV) as one of the most serious complications. Hematopoietic stem cell transplant (HSCT) is the ultimate therapy for this complication. The aim of this study was to assess the outcome and impact of HSCT on severe SCD patients with CV complications., Methods: Twenty-five consecutive transplants-naive pediatric SCD patients with CV complications underwent HSCT at our institution between 1993 and 2015, using bone marrow as stem cells source from fully match related donors were included. Neurologic evaluation was done both clinically and radiologically before transplantation and regularly following the HSCT., Results: With a median follow-up of 52.2 ± 5.8 months, the cumulative probability of overall survival (OS) at 3 years was 92.0% and event-free survival (EFS) was 88%. Significant neurologic improvements were observed in most of the patients clinically. Different neurologic complications were assessed. The neurologic manifestations before and after HSCT were hemiparesis (11, 1), seizures (13, 8), focal neurologic deficit (4, 2), loss of conscious (2, 1) headache (6, 1), and psychological symptoms (5, 2). Post-HSCT radiological imaging was done in 15 patients, which showed stabilization of CV among all., Conclusions: Allogeneic HSCT in patients with severe SCD presenting with CV complications including moyamoya vasculopathy showed favorable outcome with significant clinical neurologic improvement and stabilization of the disease. None of the patients with severe vasculopathy underwent neurological vascular by-pass surgery prior to HSCT., Competing Interests: The authors declare no conflict of interest., (Copyright 2022, Al-Jefri et al.)

Patients with advanced pyogenic spondylodiscitis can present with neurologic deficits. However, the prevalence, severity, and outcome of the neurologic deficits are not well known. A systematic review was performed to improve the knowledge of this commonly encountered clinical scenario. The considerable number of severe neurologic deficits in addition to their poor recovery, even after surgical intervention, demonstrates that the early diagnosis of pyogenic spondylodiscitis is crucial. Prompt surgical intervention is likely associated with a greater chance of improvement of neurologic status than nonsurgical treatment., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To explore the difference between tracheostomy and non-tracheostomy and identify the risk factors associated with the need for tracheostomy after traumatic cervical spinal cord injury (TCSCI)., Methods: The demographic and injury characteristics of 456 TCSCI patients, treated in the Xinqiao Hospital from 2010 to 2019, were retrospective analyzed. Patients were divided into the tracheostomy group (n = 63) and the non-tracheostomy group (n = 393). Variables included were age, gender,smoking history, mechanism of injury, concomitant injury, American Spinal Injury Association (ASIA) Impairment Scale, the neurological level of injury, Cervical Spine Injury Severity Score (CSISS), surgery, and length of stay in ICU and hospital. SPSS 25.0 (SPSS, Chicago, IL) was used for statistical analysis and ROC curve drawing. Chi-square analysis was applied to find out the difference of variables between the tracheostomy and non-tracheostomy groups. Univariate logistic regression analysis (ULRA) and multiple logistic regression analysis (MLRA) were used to identify risk factors for tracheostomy. The area under the ROC curve (AUC) was used to evaluate the performance of these risk factors., Results: Of 456 patients who met the inclusion criteria, 63 (13.8%) underwent tracheostomy. There were differences in age (χ 2 = 6.615, P = 0.032), mechanism of injury (χ 2 = 9.87, P = 0.036), concomitant injury (χ 2 = 6.131, P = 0.013),ASIA Impairment Scale (χ 2 = 123.08, P < 0.01), the neurological level of injury (χ 2 = 34.74, P < 0.01), and CSISS (χ 2 = 19.612, P < 0.01) between the tracheostomy and non-tracheostomy groups. Smoking history, CSISS ≥ 7, AIS A and, NLI ≥ C5 were identified as potential risk factors for tracheostomy by ULRA. Smoking history (OR = 2.960, 95% CI: 1.524-5.750, P = 0.001), CSISS ≥ 7 (OR = 4.599, 95% CI: 2.328-9.085, P = 0.000), AIS A (OR = 14.213, 95% CI: 6.720-30.060, P = 0.000) and NLI ≥ C5 (OR = 8.312, 95% CI: 1.935-35.711, P = 0.004) as risk factors for tracheostomy were determined by MLRA. The AUC for the risk factors of tracheostomy after TCSCI was 0.858 (95% CI: 0.810-0.907)., Conclusions: Smoking history, CSISS ≥ 7, AIS A and, NLI ≥ C5 were identified as risk factors needing of tracheostomy in patients with TCSCI. These risk factors may be important to assist the clinical decision of tracheostomy., (© 2021 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Introduction: Neurologic complications after complex adult spinal deformity (ASD) surgery are important, yet outcomes are heterogeneously reported, and long-term follow-up of actual lower extremity motor function is unknown., Objective: To prospectively evaluate lower extremity motor function scores (LEMS) before and at 5 years after surgical correction of complex ASD., Design: Retrospective analysis of a prospective, multicenter, international observational study., Methods: The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers around the world. Inclusion criteria were Cobb angle of > 80°, corrective osteotomy for congenital or revision deformity and/or 3-column osteotomy. Among patients with 5-year follow-up, comparisons of LEMS to baseline and within each follow-up period were made via documented neurologic exams on each patient., Results: Seventy-seven (28.3%) patients had 5-year follow-up. Among these 77 patients with 5-year follow-up, rates of postoperative LEMS deterioration were: 14.3% hospital discharge, 10.7% at 6 weeks, 6.5% at 6 months, 9.5% at 2 years and 9.3% at 5 years postoperative. During the 2-5 year window, while mean LEMS did not change significantly (-0.5, p = 0.442), eight (11.1%) patients deteriorated (of which 3 were ≥ 4 motor points), and six (8.3%) patients improved (of which 2 were ≥ 4 points). Of the 14 neurologic complications, four (28.6%) were surgery-related, three of which required reoperation. While mean LEMS were not impacted in patients with a major surgery-related complication, mean LEMS were significantly lower in patients with neurologic surgery-related complications at discharge (p = 0.041) and 6 months (p = 0.008) between the two groups as well as the change from baseline to 5 years (p = 0.041)., Conclusions: In 77 patients undergoing complex ASD surgery with 5-year follow-up, while mean LEMS did not change from 2 to 5 years, subtle neurologic changes occurred in approximately 1 in 5 patients (11.1% deteriorated; 8.3% improved). Major surgery-related complication did not result in decreased LEMS; however, those with neurologic surgery-related complications continued to have decreased lower extremity motor function at 5 years postoperative. These results underscore the importance of long-term follow-up to 5 years, using individual motor scores rather than group averages, and comparing outcomes to both baseline and last follow-up., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Spine surgery is one of the specialties with the highest medicolegal risk, with a legal action initiated every 17 months per practitioner. One of the most dreaded complications is an epidural hematoma with postoperative deficit. The treatment of this complication is still being debated. We therefore conducted a retrospective study of the database of a medical liability insurer to assess perioperative factors determining the liability of the surgeon or paramedical team during an expert review in the event of a postoperative symptomatic epidural hematoma., Hypothesis: To identify the factors determining the liability of the medical team in the event of a postoperative symptomatic epidural hematoma., Materials and Methods: We retrospectively analyzed the largest French register of medicolegal expert reviews between 2011 and 2018. We identified 68 cases by entering the following keywords in this database: "spine surgery," "complications," and "epidural hematoma." After a thorough review of each case, only 14 were deemed to be truly relevant to our study. We collected for each patient the perioperative data, complications (including neurologic deficits) and their clinical course., Results: Only one surgeon was accused and found liable for failing to perform a surgical revision within a reasonable timeframe (time to revision of 11 days). In 2 cases, the liability of a nurse working in the surgical department was called into question for failing to contact the surgeon upon the onset of symptoms. In the other cases (11 patients, 79%), the occurrence of a symptomatic epidural hematoma was considered a no-fault medical accident that was not caused by the surgeon. The presence of a drain did not have any medicolegal impact in the cases reviewed., Conclusion: The key element in medicolegal decisions is the reaction time of the healthcare teams, in particular the time between the onset of symptoms and surgical revision. According to these expert reviews, the placement of a drain was not taken into consideration during the medicolegal assessment of a postoperative symptomatic epidural hematoma., Level of Evidence: II; retrospective prognostic study, investigation of patient characteristics and their impact on functional outcome., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Previous studies have indicated that correction of an established kyphosis in spine tuberculosis is both difficult and hazardous. There has not been any publication about evaluation of surgical correction of spine tuberculosis in Indonesia, despite of high incidence of spine tuberculosis cases. Therefore, we evaluated the outcome of kyphotic angle correction and neurological status after surgery of spinal tuberculosis patients for better understanding., Methods: Retrospectively, 96 patients with spinal tuberculosis that underwent operation in Soeharso Orthopedic Hospital from June 2016 to July 2019 were selected. Operation procedure includes laminectomy, debridement and posterior stabilization. We obtained plain x-ray of spine to evaluate the kyphotic deformity before and after surgery. We also examined neurological status of the patient before and after surgery., Results: The average pretreatment kyphotic angle in thoracic tuberculosis was 33.69° (range 8°-86°), which improved into a significant change to 13.27° (range 0°-56°). Correction angle was <25° in 34 people, 25°-50° in 17 people, and >50° in 4 people. While in the lumbar tuberculosis, it was 25.52° (range 6°-80°), and improved into 11.51° (range 2°-48°). Correction angle was <25° in 35 people, 25°-50° in 4 people, and >50° in 2 people. Improved neurological deficit was shown in 12% of patient with lumbar tuberculosis, and the rest had constant neurological deficit. While in thoracic tuberculosis found that 7% have improved neurological deficit and the rest is constant. None of them have worsen neurological status after the surgery., Conclusions: Surgical treatment for kyphotic deformity in patient with thoracolumbar tuberculosis are effective and safe, even in high corrective angle (>50°)., Competing Interests: Declaration of competing interest All authors have none to declare., (Copyright © 2021 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Background: Glioma is the most common intra-axial tumor, and its location relative to critical areas of the brain is important for treatment decision-making. Studies often report tumor location based on anatomical taxonomy alone since the estimation of eloquent regions requires considerable knowledge of functional neuroanatomy and is, to some degree, a subjective measure. An unbiased and reproducible method to determine tumor location and eloquence is desirable, both for clinical use and for research purposes., Objective: To report on a voxel-based method for assessing anatomical distribution and proximity to eloquent regions in diffuse lower-grade gliomas (World Health Organization grades 2 and 3)., Methods: A multi-institutional population-based dataset of adult patients (≥18 years) histologically diagnosed with lower-grade glioma was analyzed. Tumor segmentations were registered to a standardized space where two anatomical atlases were used to perform a voxel-based comparison of the proximity of segmentations to brain regions of traditional clinical interest., Results: Exploring the differences between patients with oligodendrogliomas, isocitrate dehydrogenase (IDH) mutated astrocytomas, and patients with IDH wild-type astrocytomas, we found that the latter were older, more often had lower Karnofsky performance status, and that these tumors were more often found in the proximity of eloquent regions. Eloquent regions are found slightly more frequently in the proximity of IDH -mutated astrocytomas compared to oligodendrogliomas. The regions included in our voxel-based definition of eloquence showed a high degree of association with performing biopsy compared to resection., Conclusion: We present a simple, robust, unbiased, and clinically relevant method for assessing tumor location and eloquence in lower-grade gliomas., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Gómez Vecchio, Neimantaite, Corell, Bartek, Jensdottir, Reinertsen, Solheim and Jakola.)