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Background Previous studies have shown that therapeutic hypothermia could improve neurologic recovery when induced after cardiac arrest, but dynamic changes in cerebral metabolism have not been studied at low temperature. In this study, we aim to evaluate hypothermia-induced changes in pigs' cerebral metabolism by 1 H-magnetic resonance spectroscopy ( 1 H-MRS). Material and Methods Ten anesthetized Landrace (25-30 kg) pigs were randomized into 2 groups and subjected to 4 minutes of ventricular fibrillation, followed by cardiopulmonary resuscitation. The hypothermic group was given an infusion of 30 mL/kg of 4°C normal saline (NS) at an infusion rate of 1.33 mL/kg per minute starting after restoration of spontaneous circulation (ROSC), then 10 mL/kg per hour for 4 hours. The control group received the same infusion of room temperature NS. Core temperature and hemodynamic variables were monitored at baseline and repeatedly for 240 minutes after ROSC. The 1 H-MRS scans were obtained at baseline, 1 hour, and 3 hours after successful ROSC to observe the dynamic changes of cerebral metabolism at different temperatures. Results The mean reduction of temperature was 1.5°C ± 0.4°C in the hypothermic group. There was no difference in hemodynamic variables between groups. 1 H-MRS detected statistically significant ( P P Conclusions Infusion of 4°C NS can effectively reduce cerebral metabolism after successful cardiopulmonary resuscitation and have a protective effect on the recovery of neurologic function. The 1 H-MRS technology can be used as a powerful tool to evaluate interventions in the treatment of cardiopulmonary resuscitation.

We assessed the application of the proprioceptive correction method supporting stimulating foot massage "PIONt" and pull-suit "Regent" in medical rehabilitation of patients underwent spinal or cerebral strokes. The analysis of the neurological deficiency dynamics was performed; effectiveness of the neuro-rehabilitation predictors and mechanisms of proprioceptive correction method action were discussed. The significance of proprioceptive correction methods in a comprehensive restoration of neurologic function in stroke patients was shown.

Post-cardiac-arrest therapeutic hypothermia improves outcomes in comatose cardiac arrest survivors. This study tests the hypothesis that the efficacy of post-cardiac-arrest therapeutic hypothermia is dependent on the onset and duration of therapy.Prospective randomized laboratory investigation.University research laboratory.A total of 268 male Long Evans rats.Post-cardiac-arrest therapeutic hypothermia.Adult male Long Evans rats that achieved return of spontaneous circulation after a 10-min asphyxial cardiac arrest were block randomized to normothermia (37°C ± 1°C) or therapeutic hypothermia (33°C ± 1°C) initiated 0, 1, 4, or 8 hrs after return of spontaneous circulation and maintained for 24 or 48 hrs. Therapeutic hypothermia initiated 0, 1, 4, and 8 hrs after return of spontaneous circulation resulted in 7-day survival rates of 45%*, 36%*, 36%*, and 14%, respectively, compared to 17% for normothermic controls and survival with good neurologic function rates of 24%*, 24%*, 19%*, and 0%, respectively, compared to 2% for normothermic controls (*p.05 vs. normothermia). These outcomes were not different when therapeutic hypothermia was maintained for 24 vs. 48 hrs. In contrast, hippocampal CA1 pyramidal neuron counts were 53% ± 27%*, 53% ± 19%*, 51% ± 24%*, and 65% ± 16%* of normal, respectively, when therapeutic hypothermia was initiated 0, 1, 4, or 8 hrs after return of spontaneous circulation compared to 9% in normothermic controls (*p.01 vs. normothermia). Furthermore, surviving neuron counts were greater when therapeutic hypothermia was maintained for 48 hrs compared to 24 hrs (68% ± 15%* vs. 42% ± 22%, *p.0001).In this study, post-cardiac-arrest therapeutic hypothermia resulted in comparable improvement of survival and survival with good neurologic function when initiated within 4 hrs after return of spontaneous circulation. However, histologic assessment of neuronal survival revealed a potentially broader therapeutic window and greater neuroprotection when therapeutic hypothermia was maintained for 48 vs. 24 hrs.

OBJECTIVE Variability exists in the documentation of death by neurologic criteria in children. We hypothesized that the use of a note template/checklist, which included directive (educational) prompts based on institutional neurologic determination of death criteria, improved thoroughness of documentation within our institutional guidelines for the neurologic determination of death. DESIGN Retrospective chart review. SETTING Twenty-one bed pediatric intensive care unit in a freestanding pediatric teaching hospital. PATIENTS Children 0-18 yrs undergoing evaluation for cessation of neurologic function from May 2000 to June 2006. INTERVENTIONS Introduction of a computerized note template/checklist with educational prompts to document cessation of neurologic function. MEASUREMENTS AND MAIN RESULTS Documentation of 15 specific elements derived from our institution's neurologic determination of death guidelines was evaluated. Age, gender, primary diagnosis, observation interval between examinations, the use of appropriate ancillary testing, and apnea test element documentation were also studied. There were 490 deaths in the pediatric intensive care unit, of which 82 (16.7%) had at least one examination for cessation of neurologic function. Neurologic determination of death examination was performed 136 times in 78 patients (mean 1.74 examinations/patient); four charts were missing. Life support was withdrawn before the second examination in 14.1% of patients. Documentation was handwritten for 37.5% of the notes. The mean number of examination elements documented by handwritten note was 11.1 ± 2.2 vs. 14.9 ± 0.7 in the template/checklist group (p < .0001). Use of a template/checklist was associated with neurologic determination of death documentation of 98.6% of essential elements compared with 73.9% of the elements in handwritten notes (p < .0001). Compliance with intervals between examinations conformed to guidelines in 64.0% of cases. Documentation of apnea duration and pco2 increase was significantly greater with the template/checklist (p < .025 and p < .001, respectively). CONCLUSIONS Use of a note template/checklist to guide and document neurologic determination of death improved adherence to institutional criteria for assessment of cessation of neurologic function.

Traumatic spinal epidural hematoma (TSEH) is of rare clinical occurrence. We report a case of a young man with posttraumatic long-segment spinal epidural hematoma. Evacuation of the hematoma led to complete neurologic recovery in our patient. Our case highlights the importance of early diagnosis and prompt surgical intervention for the evacuation of hematoma in preservation or maximum recovery of neurologic function. Imaging findings, management options, and the relevant literature are reviewed.

Stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function in a patient. According to current methodological recommendations, it is possible to perform surgical and drug treatment to minimize the damage from acute stroke in the first 3-6 hours after the onset of transient ischemic attacks, which is often difficult to identity for emergency physician or clinician. Thermal infrared imaging could serve as a fast non-invasive test to detect asymmetrical pattern in facial temperature of patient as a predictor for vessel occlusion during acute stroke. We develop a software-driven model to simulate for dynamics of facial surface temperature distribution with transient ischemic attacks. The implemented model is designed to develop and debug algorithms for automated analysis of the temperature dysregulation at the processing of patient thermal infrared recording.

2037Background: The neurologic assessment in neuro-oncology (NANO) scale was developed as a standardized metric to objectively measure neurologic function in patients (pts) with brain tumors to com...

STUDY DESIGN Case report and literature review. OBJECTIVE To discuss the diagnosis, limitations, and treatment of combined occipital-cervical and atlantoaxial disassociation with normal neurologic function. SUMMARY OF BACKGROUND DATA Injuries to the craniocervical junction can lead to devastating neurologic deficits. Occipital-cervical disassociation is a well-documented injury pattern that can lead to pain, spinal cord injury, and death. Early diagnosis and treatment can preserve neurologic function. Combined injuries to both the occipital-cervical and atlantoaxial segments are less common and, to date, have only been described with severe neurologic injury. METHODS Retrospective review of a case. Literature review was performed through Medline and Pubmed searches. RESULTS This is the first case to present a combined occipital-cervical and atlantoaxial disassociation with a neurologically intact patient. Initial physical examination was limited, but early imaging revealed evidence of instability. Early diagnosis and early (< 24) surgical stabilization was performed with no complications and neurologic preservation. One-year follow-up visit revealed normal neurologic examination with neck pain VAS = 2/10 and neck disability index = 6. CONCLUSION Combined injuries to the occipital-cervical and atlantoaxial can result in upper cervical instability. Despite previous reports, neurologic preservation remains a possibility in this injury pattern. Limitations in physical examination and radiographic imaging persist, but early diagnosis and surgical stabilization may improve neurologic outcomes.

Background En bloc resection, with adequate surgical margins, of primary malignant bone tumors of the sacrum is associated with long term disease control and potential cure. Resection of sacral tumors is difficult due to the proximity of neurovascular and visceral structures, and complete, or even partial, sacrectomy often results in functional loss for the patient. Objective We describe the technique for en bloc resection of a sacral chordoma through a mid-sacral amputation. Results We demonstrate successful removal of a large sacral tumor with wide surgical margins while preserving neurologic function. Conclusion This technique for midsacral amputation to remove a sacral tumor en bloc minimizes local recurrence and maximizes neurovascular function.

An individual who has sustained either irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including the brainstem is dead. A person is not dead unless his brain is dead. The time-honored criteria of stoppage of the heartbeat in circulation are indicative of death only when they persist long enough for the brain to die. Brain death does not require every brain cell to be nonviable but the criteria require an irreversible loss of neurologic function of a patient interminably supported by a mechanical respirator. For death to be diagnosed by an irreversible cessation of circulation and respiration an absence of circulation should be observed for at least two but no more than five minutes. Irreversibility is determined by a "permanent" loss of function meaning that the function will not be restored 1) because it will neither return spontaneously, nor 2) will it return as a result of medical intervention because physicians have decided not to attempt resuscitation.

A human requirement for vitamin E was established in the 1960s; however, its role in neurologic function has been recognized only for the past 10 years. The neurologic syndrome of vitamin E deficiency is seen in patients with chronic steatorrhea and principally affects functions of the spinal cord posterior column and retina; however, it can also involve other parts of both the central and peripheral nervous system and the proximal muscles. This review examines the clinical and laboratory assessment of patients suspected of having vitamin E deficiency and points out the importance of recognizing the syndrome since many of the incapacitating symptoms are largely reversible.

In patients with metastatic disease to their spine and compromise of neurologic function, the challenge is to accomplish decompression of the neural elements and maintain mechanical stability but limit the risk and morbidity to the patient. In this case report the lateral extracavitary approach is employed to accomplish these tasks through a single approach in a patient with multiple non-contiguous sites of dorsal as well as ventral cord compression.

Purpose To determine the safety and feasibility of intraarterial stroke therapy for acute ischemic strokes at a community-based medical center. Materials and Methods This is a retrospective analysis of data gathered from consecutive stroke patients treated between June 2004 and April 2007. The following therapies were used to treat acute ischemic stroke within 6 hours of symptom onset: intraarterial thrombolytic drugs, intraarterial vasodilators, mechanical clot retrieval, intravascular stents, and angioplasty. The outcomes measured included posttherapy National Institutes of Health Stroke Score (NIHSS), neurologic function at 90 days graded according to the modified Rankin Scale (mRS), recanalization, symptomatic intracranial hemorrhage, and 90-day mortality. Results Eighty-three patients with a median baseline NIHSS of 17 (range, 3–30) were treated with intraarterial therapy. The median posttherapy NIHSS was 5 (range, 0–33). Forty-two patients (76%) had an mRS score of 2 or less at 90 days. The recanalization rate was 76%. Five patients (6%) had symptomatic intracranial hemorrhage, and the 90-day mortality was 22%. Conclusions The results of this review showed that an intraarterial therapeutic approach to acute ischemic stroke was feasible at a community-based heath center and demonstrated encouraging data for outcome and safety.

Stereotactic radiosurgery has enabled the delivery of higher doses of radiation and decreased fractionation due to improved accuracy. Spinal radiosurgery has been increasingly utilized for the management of metastatic extradural spinal disease. However, surgical resection remains the primary treatment strategy for intradural spinal tumors. Preliminary evidence suggests that radiosurgical ablation with stereotactic radiation for intradural spinal lesions may be efficacious in certain clinical scenarios. Local tumor control, pain relief, and improvement in neurologic function with minimal morbidity have been reported in short-term follow-up. However, long-term efficacy of radiosurgery in the management of intradural spinal neoplasms necessitates further validation. As extracranial radiosurgery is a newly evolving modality, a continuative review of the current literature is appropriate. Until a standardized therapeutic window of safety and efficacy can be determined, the recommendation of radiosurgical applications for benign spinal tumors should be reserved for carefully selected cases.

The neonatal neurologic assessment is an evaluation of neurologic function in the newborn infant. This paper provides an overview of the construct, content, and purpose of the neonatal neurologic examination. Furthermore, the reliability and validity of nine standardized neonatal assessments are reviewed.

To review the state-of-the-art and new developments in the management of patients with brain metastases.Treatment decisions are based on prognostic factors to maximize neurologic function and survival, while avoiding unnecessary therapies. Whole-brain radiotherapy (WBRT) is the treatment of choice for patients with unfavorable prognostic factors. Stereotactic radiosurgery (SRS) or surgery is indicated for patients with favorable prognostic factors and limited brain disease. In single brain metastasis, the addition of either stereotactic radiosurgery or surgery to WBRT improves survival. The omission of WBRT after surgery or radiosurgery results in a worse local and distant control, though it does not affect survival. The incidence of neurocognitive deficits in long-term survivors after WBRT remains to be defined. New approaches to avoid cognitive deficits following WBRT are being investigated. The role of chemotherapy is limited. Molecularly targeted therapies are increasingly employed. Prophylaxis with WBRT is the standard in small-cell lung cancer.Many questions need future trials: the usefulness of new radiosensitizers; the role of local treatments after surgery; and the impact of molecularly targeted therapies on subgroups of patients with specific molecular profiles. Quality of life and cognitive functions are recognized as major endpoints in clinical trials.

Objective: Neurologic outcome after cardiopulmonary resuscitation from cardiac arrest carries a poor prognosis and treatment options to ameliorate brain damage are limited. Design: Report of two protocols investigating the effects of xenon (Xe) and isoflurane (Iso) in a porcine model of prolonged cardiac arrest and subsequent cardiopulmonary resuscitation on functional neurologic outcomes. Setting: Prospective, randomized, laboratory animal study. Subjects: Male domestic pigs (Sus scrofa). Interventions: After successful resuscitation from 8 mins of cardiac arrest and 5 mins of cardiopulmonary resuscitation, pigs were randomized to receive either Xe for 1 or 5 hrs in comparison with untreated controls 1 hr after cardiopulmonary resuscitation (protocol 1) or to receive Iso or Xe in comparison with untreated controls 10 mins after cardiopulmonary resuscitation (protocol 2). Measurements and Main Results: Animals were exposed to an established cognitive function test and gross neurologic performance was assessed using a neurologic deficit score. In protocol 1, Xe administration resulted in improved early cognitive and overall neurologic function, whereas in protocol 2 there was no significant effect on functional performance. Conclusions: Although Xe conferred functional neurologic improvement even when treatment was delayed for 1 hr, the early treatment with either Xe or Iso translated to only marginal functional improvement.

Timely detection of early cognitive impairment is difficult. Measures taken in the clinic reflect a single snapshot of performance that might be confounded by the increased variability typical in aging and disease. We evaluated the use of continuous, long-term, and unobtrusive in-home monitoring to assess neurologic function in healthy and cognitively impaired elders.Fourteen older adults 65 years and older living independently in the community were monitored in their homes by using an unobtrusive sensor system. Measures of walking speed and amount of activity in the home were obtained. Wavelet analysis was used to examine variance in activity at multiple time scales.More than 108,000 person-hours of continuous activity data were collected during periods as long as 418 days (mean, 315 +/- 82 days). The coefficient of variation in the median walking speed was twice as high in the mild cognitive impairment (MCI) group (0.147 +/- 0.074) as compared with the healthy group (0.079 +/- 0.027; t(11) = 2.266, P.03). Furthermore, the 24-hour wavelet variance was greater in the MCI group (MCI, 4.07 +/- 0.14; healthy elderly, 3.79 +/- 0.23; F = 7.58, P/= .008), indicating that the day-to-day pattern of activity of subjects in the MCI group was more variable than that of the cognitively healthy controls.The results not only demonstrate the feasibility of these methods but also suggest clear potential advantages to this new methodology. This approach might provide an improved means of detecting the earliest transition to MCI compared with conventional episodic testing in a clinic environment.

Objective: To describe the serious toxicity of a readily available solvent, diethylene glycol (DEG). We describe a case of intentional ingestion of a wallpaper stripper containing DEG resulting in severe multi-system organ failure. Case Report: A 27-year-old male presented to the Emergency Department (ED) one day after ingesting wallpaper stripper containing DEG. He developed acidosis, renal cortical necrosis, hepatocellular injury, and severe neurologic sequelae, including cranial neuropathies and peripheral demyelinating sensori-motor polyneuropathy. His neurologic function improved over 5 months. Discussion: Our case demonstrates the severe toxicity of DEG. DEG is present in numerous formulations, often without proper protective packaging. DEG has been associated with severe epidemic poisonings in the past and with the availability of safer alternatives, DEG in consumer products should be eliminated. Conclusion: DEG is found in numerous products. Delays in treatment can have devastating results, resulting in death or permanent disability. The pervasive use of this compound makes further human exposures likely.

Brain injury is a major source of patient morbidity after cardiac surgery, and is associated with prolonged hospitalization, excessive operative mortality, high hospital costs, and altered quality of life. Frequency and the clinical manifestations depend on multiple factors, including the completeness and timing of neurologic testing. Ischemic brain infarctions may or may not be associated with stroke or postoperative neurocognitive dysfunction, but the long-term implications of these lesions on neurologic function have not yet been extensively evaluated. This article reviews the current views on the pathophysiologic basis of cerebral injury after cardiac surgery and provides a summary of measures aimed at reducing its occurrence.

Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.

Background: On most occasions, the diagnosis of seizures and epilepsy is considered in cases of temporary disturbance of neurologic function. In this clinical situation, the physician in charge (neurologist, emergency physician, general practitioner, intensivist, cardiologist, psychiatrist, etc.) should establish the differential diagnosis with other pathologies that can also cause transient neurologic disturbances. Review Summary: We will review the relevant literature about the diagnostic process and the differential diagnosis of epileptic seizures and epilepsy at the onset of the disease, and the medical consequences of an incorrect diagnosis. Conclusion: Neurologists and non-neurologists often diagnose epilepsy. The diagnostic challenge consists of correctly interpreting the medical history, characteristics of the episodes and physical and neurologic examination, and properly using and interpreting supplemental paraclinical tests.

The implantation of electronic devices to monitor and alter cardiac or neurologic function or to deliver pharmaceuticals is becoming commonplace. Gastrointestinal endoscopists should be attentive to the presence of implanted electronic devices and aware of the basic means for limiting risk during the use of electrocautery in patients who have such devices in place. The risk is relatively limited in most patients, and precautions for reducing risk are easily employed. Generic and specific recommendations are discussed pertinent to use of electrocautery in patients with cardiac and neurologic devices. Selected pacemaker-dependent patients with implanted intracardiac defibrillators and those with implanted deep brain stimulators or gastric pacing devices warrant specific specialty comment before endoscopy. Additional data are needed regarding the general safety of endoscopic electrocautery and the recommended precautions in these patients.

Spinal epidural hematoma is a rare clinical entity and has a varied etiology. Urgent surgical evacuation to prevent serious permanent neurologic deficits is generally indicated. We describe a case of a 52-year-old man, on oral anticoagulant therapy, who presented with Brown-Sequard syndrome due to spontaneous spinal epidural hematoma at the cervicothoracic junction. This diagnosis was initially overlooked, given the asymmetric pattern of deficit. He later underwent cervical laminectomy and had complete restoration of neurologic function.

Objective— To evaluate outcome after closed fluoroscopic-assisted application of spinal arch external skeletal fixators in dogs with vertebral column injuries. Study Design— Retrospective case series. Animals— Dogs with traumatic vertebral column injuries (n=5). Methods— Medical records of dogs with vertebral column fractures and/or luxations stabilized with spinal arch external skeletal fixator frames applied using a closed fluoroscopic-assisted technique were reviewed. Owners were contacted to obtain long-term clinical outcomes. Results— Five dogs (age range, 6–72 months; weight, 10–54 kg) had traumatic vertebral column injuries stabilized with spinal arch external skeletal fixators applied in closed fashion. Injuries involved vertebral segments of the thoracolumbar junction, lumbar spine, and lumbosacral junction. Immediately postoperatively, 4 dogs had anatomic alignment of their vertebral fracture/luxation; 1 dog had 1 mm of vertebral canal height compromise. Time to fixator removal ranged from 65 to 282 days (141±87 days). All dogs had regained satisfactory neurologic function by 3 months. At long-term follow-up (range, 282–780 days; mean 445±190 days) all dogs were judged to have good to excellent return of function by their owners. Conclusion— Successful closed fluoroscopic-assisted application of external skeletal fixators using spinal arches provided satisfactory reduction with few complications in 5 dogs. Return to function was judged to be good to excellent in all dogs at long-term evaluation. Clinical Relevance— Closed fluoroscopic-assisted application of ESF using spinal arches provided satisfactory reduction and effective stabilization of spinal fractures with few complications and should be considered as a treatment approach.

Purpose of review The question of whether to irradiate or operate may have significant consequences for successful palliation in terms of pain relief, neurologic function, and quality of life. This article reviews the relevant issues of decision making using a framework, NOMS, applied to the cervical spine. Recent findings At Memorial Sloan-Kettering Cancer Center, a decision framework is used to assess four fundamental considerations in decision making, NOMS: neurologic (N), oncologic (O), mechanical instability (M) and systemic disease and medical comorbidities (S). This framework provides a method to dissect complicated tumor issues into simple components and allows for the integration of new technologies. Currently, patients who have high-grade spinal cord compression (N) from radioresistant tumors (O) or demonstrate mechanical instability (M) are offered surgery followed by radiation. Patients with minimal or no spinal cord compression (N) and who are stable (M) are treated with radiation therapy. The evolution of surgical techniques has made decompression and instrumentation safer and more reliable. Summary The decision framework NOMS can be applied to issues relevant to decision making for the atlanto-axial and subaxial cervical spine in which they are distinct in terms of definitions of instability and indications for operation or radiation.

The treatment of metastatic spine tumors has evolved significantly over the past 20 years due largely to improvements in magnetic resonance imaging; decompressive surgical techniques, spinal instrumentation, and high-dose conformal radiation. These advances have improved our ability to provide meaningful palliation for patients who often have significant medical and cancer-related issues. Despite technical advances that have improved our ability to maintain neurologic function, stabilize the spine, and prevent local tumor recurrences, significant barriers to rehabilitation remain. This article reviews these primary barriers to rehabilitation of the cancer patient following spine surgery and emphasizes the importance of diagnostic accuracy and a comprehensive team approach to the treatment of pain and other disorders in this population.

Primary brain tumors are associated with a poor prognosis and recognized impact on physical and neurologic function. In an effort to improve poor prognosis, novel therapeutic approaches have been pursued. The impact of therapy on function has not been fully evaluated in the past, with clinical trials focused on traditional survival endpoints. Therapies to date have been associated with incremental improvements in survival that may not have been associated with improvement in functional status. Methods for evaluating this impact include health-related quality of life symptom burden and evaluation of neurocognitive function. Each approach has associated benefits and limitations based on the type of treatment and the potential impact on functional status. An essential component of trial design evaluating functional endpoints is the development of clear hypotheses, specific aims, and predefined metrics of functional change related to each measure. This paper reviews these three approaches and discusses their potential use in evaluation of therapies for patients with primary brain tumors.

There is an urgent need for effective therapies to restore neurologic function and decrease disability following traumatic brain injury (TBI). Here, emerging findings on the mechanisms of post-TBI neural repair and regeneration, as well as therapeutic implications, are selectively reviewed.Recent discoveries include the characterization of the inhibitory signaling systems within the injury site, postinjury stem cell niche activation, the role of serotonin signaling in repair, and environment enrichment. A potentially transformative finding has been the identification of exosomes, nano-sized extracellular vesicles which have key roles in cell signaling, and might serve as novel biomarkers and as vehicles for targeted delivery of repair-inducing molecules.In the experimental setting, post-TBI repair can be promoted by modulation of inhibitory signaling, neurotrophic factor administration, and amplified serotonin signaling; additional strategies include mobilization of endogenous stem cell populations, exogenous cell-based therapies, and environmental enhancement. Feasibility, safety, and efficacy of these approaches need further investigation in humans. Studies are also needed to evaluate biomarkers based on molecular traces of neural repair and regeneration, which could transform prognostic and predictive modeling of post-TBI recovery trajectories.

E T /B S experiments would be performed to explore the mechanisms of the observed cerebral protections. Dr Lawton. But are there other ways you could specifically implicate that as the mechanism for the benefit you see? Maybe in future studies. I have a couple concerns regarding translation in the future to human benefit. So the first would be the fact that you gave your anti-miRNA 5 days before the deep hypothermic circulatory arrest. The second one is in your neurologic function you showed that there were no differences after 9 days or 14 days. In other words, the benefit of the inhibition of the miRNA was lost. Do you think these benefits would be more long term if you looked at something else? Dr Gu. It does need some time to achieve better transfection effects after injection of lentiviral vectors. In general

Aims Developmental stuttering is now generally considered to arise from genetic determinants interacting with neurologic function. Changes within speech-motor white matter (WM) connections may also be implicated. These connections can now be studied in great detail by high-angular-resolution diffusion magnetic resonance imaging. Therefore, diffusion spectrum imaging was used to reconstruct streamlines to examine white matter connections in people who stutter (PWS) and in people who do not stutter (PWNS). Method WM morphology of the entire brain was assayed in 8 right-handed male PWS and 8 similarly aged right-handed male PWNS. WM was exhaustively searched using a deterministic algorithm that identifies missing or largely misshapen tracts. To be abnormal, a tract (defined as all streamlines connecting a pair of gray matter regions) was required to be at least one 3rd missing, in 7 out of 8 subjects in one group and not in the other group. Results Large portions of bilateral arcuate fasciculi, a heavily researched speech pathway, were abnormal in PWS. Conversely, all PWS had a prominent connection in the left temporo-striatal tract connecting frontal and temporal cortex that was not observed in PWNS. Conclusion These previously unseen structural differences of WM morphology in classical speech-language circuits may underlie developmental stuttering.

Significant deficiencies of both fat- and water-soluble vitamins have been reported to occur after malabsorptive bariatric surgery. However, despite the potential for neurologic manifestations of such deficiencies, few cases of central neurologic dysfunction have been reported. Our group previously reported reversible neurologic dysfunction as an unusual manifestation of vitamin deficiency in a postjejunoileostomy patient. We report on a second case of reversible neurologic dysfunction associated with severe, prolonged vitamin deficiency many years after jejunoileostomy. Neurologic function returned to normal with vitamin repletion. Patients who have undergone malabsorptive surgery are at risk of late metabolic complications and should be closely monitored.

Spontaneous intracerebral hemorrhage (ICH) is associated with the highest mortality of all cerebrovascular events, and most survivors never regain functional independence. Many clinicians believe that effective therapies are lacking for patients who have ICH; however, this perception is changing in light of new data on the pathophysiology and treatment of this disorder, in particular, research establishing the role of medical therapies to promote hematoma stabilization. This article discusses the basic principles of management of ICH, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. In addition, minimally invasive surgery to reduce clot size is discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.

The prehospital care of patients with spinal cord injury has improved significantly since the founding of the Emergency Medical Services (EMS) in 1971. Rapid and safe transport of the spinal injury patient allows for early medical stabilization and institution of measures designed to preserve and possibly improve neurologic function. The adoption of systematic imaging protocols and advancements in imaging technology have allowed for early diagnosis of spinal injuries and therefore definitive treatment. Controversy still exists as to the basic imaging requirements needed to exclude the presence of spinal injury or the need for prereduction magnetic resonance imaging in a patient with a cervical facet dislocation.

With significant advances in surgical technology and methodology, mortality from congenital heart surgery has been significantly reduced in recent decades. Therefore, focus has naturally turned towards predicting, evaluating, and preventing the neurodevelopmental morbidity associated with congenital heart disease and its treatment. This paper reviews recent publications evaluating preoperative neurologic abnormalities and injuries, current neurodevelopmental outcomes of congenital heart repair, and various neuromonitoring modalities that can be used to monitor neurologic function/ dysfunction perioperatively. The rapidly advancing field of clinical neuromonitoring holds the promise of providing modalities that can detect injurious processes acutely to allow for intervention.

The number of patients who will develop metastatic spinal tumors is estimated to be between 5 and 10% of all cancer patients. As the therapy for systemic cancer improves, the number of patients developing symptomatic spinal tumors that require local therapy will increase. Over the last 10 years there has been a dramatic evolution in our ability to treat spinal tumors. These advances have not only been created by improvements in surgical techniques and instrumentation, but also developments in radiographic imaging, radiation therapy and chemotherapy. It is important for spine surgeons, radiologists, and radiation and medical oncologists to continue developing techniques for spinal salvage that will improve pain relief, achieve mechanical stability, improve or maintain neurologic function and sustain local tumor control. The evolution of these technologies will help to provide palliation and improve quality of life for patients with metastatic disease.

The purpose of this review is to discuss the contemporary diagnosis and treatment options for nerve sheath tumors. Common nerve sheath tumors include schwannomas, neurofibromas and malignant nerve sheath tumors. Nerve sheath tumors can be associated with genetic disorders such as neurofibromatosis and schwannomatosis. There is great variation in terms of tumor location, clinical presentation and treatment strategy. Magnetic resonance imaging is the diagnostic study of choice for nerve sheath tumors and surgery has become the mainstay of treatment for most symptomatic lesions. Progress in microsurgical techniques has resulted in significant improvement in surgical outcome, with preservation of neurologic function. Complete resection of benign nerve sheath tumors is the goal of surgical intervention and this results in cure. In contrast, malignant nerve sheath tumors remain a major challenge with poor outcomes overall. Progress in multidisciplinary research may ultimately lead to novel therapeutic strategies.

Disease of or injury to the central nervous system is a common rea-son for hospital admission on an emergency basis in veterinary medicine. Head injuries, seizures, and diseases that lead to intra-cranial hypertension frequently result in significant alteration of neurologic function. A thorough understanding of the pathophysiologic disturbances that occur during these conditions is para-mount for providing stabilizing emergent care. A detailed approach that focuses on meticulous physical evaluation, provision of timely and optimal stabilizing treatment, and continued monitoring can aid in improving outcomes in animals with signs and symptoms of neurologic disease or injury.

Metastases to the vertebrae are a common problem in the practice of a spine surgeon. Therapeutic intervention can alleviate pain, preserve or improve neurologic function, achieve mechanical stability, optimize local tumor control, and improve quality of life. Treatment options available for metastatic spine tumors include radiation therapy, chemotherapy and surgery. This article is focused on the decision making for spine surgeons and shows the protocol to treat spinal metastases at the University Hospital of Regensburg, Germany.

Multiple sclerosis (MS) is an immune-mediated neurologic disease in which acute inflammatory events early in the disease course contribute to subsequent neurologic disability. The early relapsing inflammatory phase is followed by a progressive degenerative phase in which the frequency of acute inflammatory attacks diminishes but progressive loss of neurologic function continues. Current immune therapies are most effective in suppressing the acute inflammatory events that characterize the earlier stages of disease. Optimal suppression of these inflammatory events is likely to have the best potential for delaying or preventing loss of axons and decline in neurologic function. In view of these considerations, and because MS is a heterogeneous disease and response to disease-modifying agents (DMA) varies across individuals, it is important to identify suboptimal responders as early as possible to allow therapeutic modification while the opportunity to avert future loss of function remains. At present, no criteria for identifying suboptimal responders have been validated. In January 2004, a group of neurologists from 16 MS centers in the United States met to develop a consensus on criteria for defining suboptimal response for use in compelling clinical situations and to prompt clinical studies to validate the efficacy of these criteria. Consensus criteria included relapse rates of either 1/year or unchanged from pretreatment rates, incomplete recovery from multiple attacks, evolution of polyregional neurologic involvement, recurrent brainstem or spinal cord lesions, and cumulative loss of neurologic function sufficient to disrupt daily activities. The panel then considered the use of mitoxantrone for patients with worsening MS and a suboptimal response to DMA therapy.

Ozone-depleting solvents, such as specific chlorofluorocarbons and 1,1,1-trichloroethane, have been banned since 1996 in developed countries. Because they were used in large amounts in various industries, alternative compounds were introduced to the workplace. One such alternative compound is 1-bromopropane (1-BP; n-propylbromide, CAS Registry no. 106-94-5), which is used in the United States and Japan as a cleaning agent for metals, precision instruments, electronics, optical instruments, and ceramics (Ichihara, in press). It is also used in spray form as an adhesive in the United States (Ichihara et al. 2002). Environ Tech (2001) estimated the total amount of 1-BP commercially available for sale in the United States in the year 2000 was 1,967.9 metric tons (4,338,583 lb), which is comparable to 9.0, 31.0, and 10.6% of the amount of methylene chloride, perchloroethylene, and trichloroethylene used in adhesive/foam fabrication and metal cleaning in the same year in the United States. In Japan, the amount of 1-BP sold in 2003 was 1,125 metric tons, which is about double the 645 metric tons sold in 1998 (Association of Bromopropane Producers of Japan, unpublished data). In addition, in the workplace where cases of neurotoxicity had been reported, 1-BP was introduced as an alternative for methylene chloride (Ichihara et al. 2002). The benefits of using 1-BP instead of the chlorinated carbons are not clear. However, under pressure to regulate the use of chlorocarbons, 1-BP has been used as a surrogate, which is encouraged by the lack of measures to define the exposure limits. In this regard, previous animal studies revealed neurotoxicity and reproductive toxicity of 1-BP (Ichihara et al. 2000a, 2000b; Wang et al. 2002, 2003; Yamada et al. 2003; Yu et al. 1998, 2001). Exposure to 1-BP resulted in a dose-dependent limb muscle weakness and reduction of nerve conduction in rats (Ichihara et al. 2000a). It also resulted in myelin degeneration of peripheral nerves and swelling of preterminal axons in the medulla oblongata (Ichihara et al. 2000a). It was also revealed that 1-BP exhibits reproductive toxicity in both male and female rats (Ichihara et al. 2000b; Yamada et al. 2003). Thus, animal studies preceded human studies and warned about the potential neurotoxicity and reproductive toxicity of 1-BP in humans. The most recently reported cases also confirmed the neurotoxicity of 1-BP in humans (Ichihara et al. 2002; Sclar 1999). However, these case reports have limitations in terms of quantitative analysis. In 1999 we investigated a 1-BP factory, but this investigation was also limited because it was originally oriented to study the effects of 2-bromopropane (2-BP), which targets mainly reproductive and hematopoietic systems (Ichihara et al. 2004). The aim of the present study was to assess the neurologic function and other health-related changes in workers exposed to 1-BP and compare the results with those of control workers in a beer factory.

Tumors of peripheral nerve origin are usually slow growing and minimally symptomatic, making differentiation from other soft tissue neoplasms difficult. Yet failure to recognize a nerve tumor may result in irreversible loss of neurologic function. This article provides current information on the history, pathologic identification, and treatment of upper extremity nerve tumors. Other neoplastic and tumor-like lesions that occur within the peripheral nerve are also considered.

Dyspnea is a subjective experience that can be reported by the patient. Respiratory distress is an observable corollary, and represents the physical or emotional suffering that results from the experience of dyspnea. Recognizing and understanding this subjective phenomenon poses a challenge to intensive care unit (ICU) clinicians when caring for the patient who is dying in the ICU. Dyspnea and cognitive impairment are highly prevalent in the terminally ill ICU patient. A Respiratory Distress Observation Model may provide a theoretical foundation for the assessment of this phenomenon that is grounded in emotional and autonomic domains of neurologic function. Treatment of dyspnea and respiratory distress relies on nonpharmacologic interventions and opioids and sedatives. As with pain, the treatment of dyspnea and respiratory distress relies on close evaluation of the patient and treatment to satisfactory effect. Empirical evidence suggests that quality care with control of distressing symptoms does not hasten death. Withholding opioids or sedatives in the face of unrelieved dyspnea or respiratory distress has no moral foundation.

Although general anesthesia allows relief from stressors such as pain, discomfort, or anxiety for patients undergoing carotid endarterectomy, neurologic assessment is less reliable than under local anesthesia. We describe a unique anesthetic management strategy for carotid endarterectomy patients incorporating the advantages of both general and local anesthesia. The technique allows thorough assessment of neurologic function during carotid cross-clamping by intraoperative wake-up, and guarantees airway management by tracheal intubation.