Pneumocephalus and Brown‐Sequard syndrome caused by a stab wound to the back

This report describes a case of Brown‐Sequard syndrome in a man who presented to the ED after a stabbing to the left scapula region. The incidental finding of pneumocephalus found on CT scan during workup lead to cervical MRI that revealed the spinal cord pathology associated with Brown‐Sequard syndrome.     

A Case Report: An Acute Spinal Epidural Hematoma after Acupuncture Mimicking Stroke

BackgroundSpinal epidural hematoma (SEH) after acupuncture is rare and may present with acute or subacute onset and varied symptoms, making it difficult to diagnose. This condition can mimic acute stroke, so it is vital to establish a clear diagnosis before considering thrombolytic therapy, which could be disastrous if applied inappropriately.Case ReportWe describe a 52-year-old man who presented to our emergency department (ED) with acute onset of unilateral weakness of the limbs for 3.5 h immediately after receiving acupuncture at the bilateral neck and back. The acute stroke team was activated. In the ED, computer tomography angiography from the aortic arch to the head revealed spinal epidural hematoma. The patient was admitted to the ward for conservative treatment and was discharged with subtle residual symptoms of arm soreness 5 days later.Why Should an Emergency Physician Be Aware of This?Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs, mimicking a stroke. Because inappropriate thrombolysis can lead to devastating symptoms, spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a history of acupuncture who is a possible candidate for thrombolytic therapy.     

Brown–sequard syndrome due to isolated blunt trauma

Blunt trauma without associated fracture or ligamentous injury is a rare cause of Brown–Sequard syndrome. We report a case of Brown–Sequard syndrome after a direct blow to the cervical spine that did not cause injury to adjacent bone or ligaments. Characteristic neurologic findings, including a unilateral hemiparesis with associated contralateral sensory findings, were noted at the time of presentation. High-dose steroids were instituted after recognition of the patient’s injury, and magnetic resonance imaging of the cervical spine revealed a unilateral cord contusion with no associated fractures. After 1 month, the patient had recovered much of his function and was able to ambulate unassisted.     

Cervical spinal epidural hematoma mimics acute ischemic stroke

Spinal epidural hematoma is an accumulation of blood in the epidural space that can mechanically compress the spinal cord. It is an uncommon condition, and most cases occur spontaneously. Detailed evaluation of neurologic deficit and detailed history taking are important tools for early diagnosis, and magnetic resonance imaging is currently the diagnostic method of choice. Prompt surgical intervention is important in achieving positive clinical outcomes. Spinal epidural hematoma usually comes with acute, severe pain with radiation to the extremities and may be accompanied with severe neurologic deficit. Common neurologic signs include paraparesis and quadriparesis. Here, we report 2 cases of cervical spinal epidural hematoma with sudden onset of neck pain, followed by the development of unilateral limbs weakness and respiratory distress. Both patients were initially suspected to have acute ischemic stroke and were considered using intravenous thrombolytic therapy with recombinant tissue plasminogen activator as treatment. Cervical spinal epidural hematoma was confirmed after obtaining magnetic resonance imaging. Patients with this uncommon presentation must be carefully distinguished from acute stroke. This article aimed to highlight the potential pitfalls in diagnosing acute hemiparesis with no cranial nerves deficits and the importance of clinical suspicion.     

颈椎后路减压与脊髓后移位距离及轴性症状的关系

背景：颈椎后路治疗后脊髓后移位距离受多方面因素的影响,实质是脊髓受到外力后的一种形态学改变。目的：分析脊髓型颈椎病行颈后路单开门椎管成形减压后脊髓后移的影响因素。 方法：回顾性分析70例多节段脊髓型颈椎病行颈后路单开门椎管成形减压患者的病例资料,根据患者治疗后MRI脊髓后移位的距离不同将其分为3组：5 mm组。采用日本骨科协会（JOA）评分、颈椎曲度改变程度、轴性症状指标评估比较。 结果与结论：3组间日本骨科协会（JOA）评分恢复率差异无显著性意义;3组患者治疗前后颈椎曲度的改变差异无显著性意义。治疗后脊髓后移〉5 mm组患者表现轴性症状的比例显著高于其他两组（P〈0.05）。提示脊髓型颈椎病行颈后路减压后脊髓后移位的距离与治疗后的轴性症状有关联。     

规范程序化康复处理在内固定术治疗上位颈椎疾患术后的应用

目的探讨术后康复处理对上位颈椎疾患手术效果的作用,以了解内固定术治疗上位颈椎疾患术后的康复处理方法。方法应用内固定术治疗上位颈椎疾患20例,其中陈旧性齿突骨折11例,新鲜齿突骨折5例,寰枢椎脱位伴颅底凹陷4例。手术方法经后路17例:Apofix寰枢复位内固定植骨融合术12例,寰椎后弓切除、枕骨大孔减压、枕颈CD或CCD内固定及枕颈植骨融合术5例。经前路3例,行齿突螺钉内固定术。术后依照作者所制定原则进行综合的康复处理,康复过程中强调头颈部中立位的牢靠外固定,以及循序渐进的肢体功能康复训练。术前JOA颈髓症评分5～17,平均13.2。结果1例陈旧性齿突骨折伴寰枢椎脱位患者因术后2d不配合,擅自放松颈围、垫高枕,致再发寰椎旋转移位,出现脊髓压迫症状而再次手术,其余均未出现并发症。全部病例随访6～24个月,平均13.7个月。JOA颈髓症评分10.5～17.0,平均16.3。影像学显示植骨区均已骨性融合。结论规范程序化的术后康复处理是内固定术治疗上位颈椎疾患取得良好疗效的重要保证。     

椎弓根钉棒系统固定治疗齿状突骨折合并寰枢关节不稳

[目的]探讨椎弓根钉棒系统固定治疗创伤性枢椎齿状突骨折合并寰枢关节不稳的方法与疗效.[方法]2005年12月至2010年4月共治疗枢椎齿状突骨折合并寰枢关节不稳的成年患者26例,均为急性损伤;按Grauer 改良的Anderson-D′Alonzo 分型,ⅡA 型5例,ⅡB 型12 例,ⅡC 型6例,Ⅲ型3 例.3 例...     

急性脱髓鞘性脊髓病临床特点初探

目的探讨急性脱髓鞘性脊髓病的临床特点及其早期诊断。方法回顾性分析14例急性脱髓鞘性脊髓病患者的临床资料。结果急性脱髓鞘性脊髓病多为亚急性发病,首发症状以感觉障碍为主,感觉平面逐渐上升,运动、自主神经功能障碍相继出现与加重,瘫痪存在不对称性;MRI检查呈等T1、长T1、长T2信号,病灶累及颈胸髓;无中枢神经系统其他病灶,病程单时相;脑脊液检查缺乏特异性诊断指标。结论急性脱髓鞘性脊髓病可作为脱髓鞘疾病中的一类诊断。     

Thrombolytic therapy for ischemic stroke--a review. Part I--Intravenous thrombolysis

OBJECTIVE: Thrombolytic therapy for acute ischemic stroke was implemented into clinical routine 4 yrs ago. Unfortunately, at present <2% of eligible patients receive thrombolytic therapy. We present an overview of all hitherto completed trials of intravenous thrombolytic therapy for carotid artery stroke including recommendations for therapy and diagnostic procedures and their impact on patient selection and meta-analyses. DATA SOURCES: We performed an extensive literature search not only to identify the larger and well-known randomized trials but also to identify smaller pilot studies and case series. Trials included in this review, among others, are the National Institute of Neurologic Disorders and Stroke (NINDS) study, European Cooperative Acute Stroke Study I and II, and Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) A and B and two large meta-analyses, including the Cochrane Library report. CONCLUSION: Intravenous thrombolytic therapy with recombinant tissue plasminogen activator has demonstrated a significant benefit and has proven to be safe for patients who can be treated within 3-6 hrs after symptom onset. This benefit is at the cost of an increased rate of symptomatic intracranial hemorrhage without a significant effect on overall mortality. In general, the benefit of thrombolysis decreases and the risks increase with progressing time after symptom onset. Presently, thrombolytic therapy is still underutilized because of problems with clinical and time criteria, and lack of public and professional education to regard stroke as a treatable emergency. If applied more widely, thrombolytic therapy may result in profound cost savings in health care and reduction of long-term disability of stroke patients.     

Anti-venom-induced myelopathy in a semipoisonous snakebite

A 40-year-old woman developed myelopathy manifesting as Brown Sequard syndrome after administration of Anti-venom (polyvalent enzyme-refined equine globulin supposed to neutralise 0.6 mg of standard cobra venom, 0.45 mg of standard krait venom, 0.6 mg of standard Russel's viper venom and 0.45 mg of saw scaled viper venom, manufactured by Serum Institute of India, Pune, India). It was concluded to be an immunological inflammation of the spinal cord after ruling out hematomyelia on imaging. The necessity of antivenom in semipoisonous snake bites have been addressed further in the article.     

Early reoccurrence of traumatic posterior atlantoaxial dislocation without fracture: A case report

BACKGROUNDIn general, atlantoaxial dislocation is rare due to the stability of the C1-C2 complex. Traumatic atlantoaxial dislocations are usually anterior and accompanied by odontoid fractures. Posterior atlantoaxial dislocations are rare, and complete posterior dislocation without associated fracture is even more rare. A case of early recurrence of posterior atlantoaxial dislocation without fracture being in therapy of first closed reduction and then open reduction has not been previously reported.CASE SUMMARYA 45-year-old female presented with traumatic posterior atlantoaxial dislocation (TPAD) of C1-C2 without associated fractures, and Frankel Grade B spinal cord function. She was successfully managed by immediate closed reduction under skull traction. Unexpectedly, 17 d later, re-dislocation was discovered. On day 28, closed reduction was performed as before but failed. Then, open reduction and posterior internal fixation with autologous iliac bone grafts was performed. By 6 mo after surgery, atlantoaxial joint fusion was achieved, and neurological function had recovered to Frankel Grade E. At 12 mo follow-up, she had lost only 15° of cervical rotation, and atlantoaxial complex instability in joint flexing and extending were no longer observed under fluoroscopy.CONCLUSIONEarly assessment of transverse ligament is critical for TPAD without fracture avoiding re-dislocation after closed reduction.     

MRI在诊断寰枢关节半脱位的应用价值

目的 探讨MRI T2WI STIR序列在诊断寰枢关节半脱位中的价值.方法 对28例有头颈部外伤、X线或CT检查发现齿状突不居中患者应用MRI T2WI STIR序列对寰枢关节进行扫描,评价横韧带损伤情况,结合临床,对寰枢关节损伤情况进行评价,指导临床治疗.结果 所有患者寰枢关节骨质均未见骨折征象,脊髓均未见受压损伤征象;横韧带位于双侧侧块内侧和齿状突后方,显示清楚,T2WI STIR序列均呈均匀低信号影;均未见到齿状突断裂征象.结论 MRI T2WI STIR序列对寰枢关节横韧带显示良好,对齿状突不居中的头颈部外伤患者有鉴别诊断价值.     

Delayed massive cerebral infarction after perioperative period of anterior cervical discectomy and fusion: A case report

BACKGROUNDCerebral infarction is an extremely rare postoperative complication of anterior cervical discectomy and fusion (ACDF), particularly in the delayed setting. We present a case who had a sudden stroke on day 18 after surgery. By sharing our experience with this case, we hope to provide new information about stroke after anterior cervical surgery. CASE SUMMARYWe present the case of a 61-year-old man with more than 20 years of hypertension and 14 years of coronary heart disease who had suffered a stroke 11 years ago. The patient was admitted for a multiple ACDF due to symptoms of cervical spondylotic myelopathy and had a sudden stroke on day 18 after surgery. Imaging findings showed a large-area infarct of his left cerebral hemisphere and thrombosis in his left common carotid artery. With the consent of his family, the thrombus was removed and a vascular stent was implanted through an interventional operation. Forty days later, the patient was transferred to a rehabilitation hospital for further treatment. He had normal consciousness but slurred speech at the 1-year follow-up evaluation. The motor and sensory functions of his hemiplegic limbs partially recovered.CONCLUSIONThis case illustrated that a postoperative stroke related to anterior cervical surgery may be attributed to prolonged carotid retraction and might have a long silent period. Preventive measures include careful preoperative and postoperative examination for high-risk patients as well as gentle and intermittent retraction of carotid artery sheath during operation.     

前路松解与后路钉棒置入融合治疗难复性寰枢关节脱位：1年随访

背景：经口前路松解后路融合内固定已成为治疗难复性寰枢关节脱位的主流治疗方法,但目前还缺乏长期疗效观察。 目的：观察经口前路松解后路融合及钉棒置入内固定治疗难复性寰枢关节脱位的临床疗效。 方法：经口前路松解后路融合内固定治疗难复性寰枢关节脱位患者32例,治疗后行颈椎正侧位数字化DR及颈椎MRI影像学检查了解神经压迫解除情况和骨性融合情况;治疗前、治疗后6个月及末次随访时采用JOA评分评定患者神经功能恢复情况。 结果与结论：治疗后29例获得随访,平均随访12个月。①所有患者均获得良好的寰枢关节复位和骨性融合,实现了复位与重建脊柱稳定性的双重目的。②所有患者治疗后脊髓受压明显减轻,神经功能均获得不同程度改善,治疗后6个月及末次随访JOA评分与治疗前比较,差异均有显著性意义（P 〈0.05）。③所有患者治疗过程中均无脊髓、椎动脉损伤等严重并发症发生,治疗后无感染、破溃等并发症发生。④影像学检查显示,经口前路松解后路融合内固定是治疗难复性寰枢关节脱位的一种安全有效的方法。     

6排螺旋CT三维重建及血管成像对颅颈交界畸形诊断的研究

目的:研究6排螺旋CT三维重建及血管成像对诊断颅颈交界畸形的价值。材料与方法:18例经手术治疗的颅颈交界畸形患者,术前均做6排螺旋CT检查.并行三维重建,分析椎体骨质的异常情况及椎动脉相互关系。结果:寰枢椎脱位11例(前脱位),寰枕融合12例,齿状突型颅底陷入4例,颈椎融合6例,扁平颅底2例,寰椎前后弓未闭合3例.外伤后齿状突骨折合并寰枢椎脱位2例,外伤后枢椎假关节形成,齿状凸与寰椎前弓相融合2例,齿状突发育不全l例,椎基底动脉供血不足3例,Arnold-chiari畸形9例。结论:6排螺旋CT血管造影结合多种三维重建方法可同时观察骨结构与血管走行及周围软组织关系,能够正确诊断并能发现少见的畸形.对于颅颈交界区畸形患者手术方案及手术入路的选择是非常重要的临床应用价值。     

寰枢椎融合与颈枕融合治疗上颈椎疾患的临床疗效比较

目的 探讨寰枢椎融合与颈枕融合在治疗上颈椎疾患的优劣性,并予指导临床内固定方式的选择.方法 我院2007年3月至2011年5月共收治52例上颈椎疾患行颈后路椎弓根钉固定技术的患者,男35例,女17例,年龄16～ 69岁,平均46岁.其中齿状突骨折21例,不稳定Hangman骨折18例,枕寰枢椎发育异常4例,Jefferson骨折3例,类风湿性关节炎伴寰枢椎脱位2例,AndersonⅡ型合并寰椎后弓骨折2例,寰椎椎管内巨大神经鞘瘤1例,枢椎齿状突基底部陈旧性骨折伴寰枢椎半脱位1例.其中36例患者合并不同程度颈脊髓损伤.脊髓损伤按Frankel分级：A级2例,B级5例,C级3例,D级6例,E级20例.根据融合节段不同分别行颈枕融合（A组）11例;寰枢椎融合（B组）41例.结合JOA法及颈部活动丢失度来评估患者临床疗效,两组病例年龄、术前JOA评分、术前颈椎活动度无统计学差异.结果 所有患者均顺利完成手术,术中、术后未出现并发症,均获得12 ～46个月随访,平均21.3个月.两组病例术后JOA评分无统计学差异（P＞0.05）,但侧屈、旋转、屈伸活动丢失率两两比较差异有统计学意义（P＜0.05）,寰枢椎融合较颈枕融合后颈部活动丢失率明显较低（P＜0.05）.术后复查X线见植骨融合,无内固定物松动或断钉现象.结论 寰枢椎融合及颈枕融合均能取得满意的植骨融合和神经症状缓解,但相比枕颈融合,寰枢椎融合对颈椎的屈伸活动度影响较小,应为上颈椎疾患的首选手术方式.但针对某些必须行颈枕融合的病例需严格掌握适应证,结合病因采用相应的手术方式和内固定类型.     

Lingual angioedema after alteplase treatment in a patient with acute ischemic stroke

BACKGROUND: In recent years, thrombolytic therapy has become the main treatment of ischemic stroke. But the increasing use of alteplase in ischemic stroke has made some complications more evident. Angioedema is a rare but potentially life-threatening complication of alteplase treatment. Only a few studies have examined the incidence of angioedema after treatment with alteplase for stroke.METHODS: A 75-year-old man complaining of right hemiparesis was admitted to our emergency department. He was diagnosed as having acute ischemic stroke, and alteplase infusion was given two hours after the onset of stroke symptoms. Immediately after the completion of infusion he was noted to have a large swollen tongue.RESULTS: His neurological symptoms resolved gradually within 4 hours, whereas his upper extremity strength improved to 4/5 and lower extremity 5/5. Lingual edema resolved within 16 hours without any complication. He died from presumed nosocomial infection 5 days later.CONCLUSIONS: Lingual angioedema may appear as a possible complication in patients who were treated with alteplase. The management of these patients should be very careful.     

Predictive value of the Cincinnati Prehospital Stroke Scale for identifying thrombolytic candidates in acute ischemic stroke

BackgroundDespite the usefulness of the Cincinnati Prehospital Stroke Scale (CPSS) for rapid recognition of acute stroke, its ability to assess stroke severity is unclear. We investigated the usefulness of CPSS for assessment of stroke severity by comparing CPSS and National Institutes of Health Stroke Scale (NIHSS) scores in patients who were candidates for thrombolytic therapy at hospital admission within 6 hours of symptom onset.MethodsWe conducted a retrospective analysis of a prospective registry database of consecutive patients included in the brain salvage through emergency stroke therapy program. In the emergency department, CPSS score was determined by emergency medical technicians. A CPSS cut-off score was estimated for candidates of thrombolytic therapy by comparing CPSS and NIHSS scores of patients who actually received thrombolytic therapy. Clinical outcomes were compared among patients with scores near the cut-off. Independent predictors of outcome were evaluated by multivariate logistic regression analysis.ResultsStrong correlations were observed between CPSS and NIHSS scores within 3 hours (R = 0.778) and 6 hours (R = 0.769) of symptom onset. The optimal cut-off score was 2 for CPSS was associated with actual usage of intravenous tissue plasminogen activator (odds ratio [OR] 34.455; 95% confidence interval [CI] 7.924-149.817, P < .0001) and actual usage of thrombolytic therapy overall (intravenous tissue plasminogen activator or intra-arterial urokinase) (OR 36.310; 95% CI 10.826-121.782, P < .0001).ConclusionThe CPSS is an effective prehospital stroke scale for the determination of stroke severity and identification of candidates for thrombolytic therapy.     

Sudden onset of cervical spondylotic myelopathy during sleep: a case report

Cervical spondylotic myelopathy is a common cause of compressive spinal cord dysfunction. The typical course involves either a gradual or an episodic increase in symptoms and neurologic deficits, with impairment evolving over a period of months to years. Acute neurologic deterioration in conjunction with cervical spondylosis has been described almost exclusively in traumatic situations such as disk herniation. We report a case of an acute, nontraumatic onset of tetraplegia in association with cervical spondylosis. A 56-year-old man developed tetraplegia during a 1-hour nap, with loss of volitional control of his extremities, impaired sensation below the C3 dermatome, and increased muscle tone. Magnetic resonance imaging of the cervical spine revealed canal stenosis and increased T2 signal within the cord. This case report describes the rehabilitation course for this patient and reviews the clinical spectrum of onset and progression of cervical spondylotic myelopathy.     

Alteplase for acute ischemic stroke

Alteplase, an intravenously administered form of recombinant tissue plasminogen activator (rt-PA), remains the only US FDA-approved thrombolytic treatment for acute ischemic stroke within 3 h of symptom onset. Patients treated with intravenous rt-PA are at least 30% more likely to have minimal or no disability at 3 months compared with placebo. Despite an increased risk of symptomatic intracranial hemorrhage, rt-PA does not increase mortality. The benefit achieved with rt-PA is cost effective and sustained 1 year after treatment. Despite its clear benefit, rt-PA remains underutilized. Although the future of acute ischemic stroke treatment will most likely involve a multi-faceted treatment approach, the primary objective remains to establish recanalization of the involved vessel. For patients with acute ischemic stroke within the first 3 h of symptom onset, rt-PA remains the first step in accomplishing this goal.