Dual-Energy CT to Diagnose Pseudoedema in Contrast-Induced Encephalopathy Following Cerebral Angiography

Background

Contrast-induced encephalopathy (CIE) is a syndrome that may be clinically unrecognized and misdiagnosed as cerebral edema.

Methods

Case report and review.

Results

A 72-year-old woman was admitted for elective endovascular embolization of a 10-mm left anterior communicating artery aneurysm. One hour post-procedure, she acutely developed global aphasia. Emergent head computed tomography (CT) and computed tomography-angiography (CTA) showed high attenuation of the left hemispheric subarachnoid spaces interpreted as hemispheric edema; emergent magnetic resonance imaging revealed left hemispheric punctate infarcts. At 12 h, she developed right hemiparesis and encephalopathy. Repeat CTA and CT perfusion revealed decreased left hemisphere cerebral blood flow and diminutive caliber of distal left middle cerebral artery territory vasculature. Repeated angiography with intra-arterial verapamil and systemic blood pressure augmentation were performed for presumed vasospasm. At 20 h, head CT was concerning for worsening left hemispheric edema, but dual-energy, iodine-subtracting sequences revealed significant contrast extravasation contributing to the appearance of sulcal effacement but without actual edema. Out of concern for blood–brain barrier breakdown from CIE, pressor augmentation was discontinued and the patient gradually improved to full neurological recovery within 72 h of symptom onset.

Conclusions

Our case is the first known to report the use of dual-energy, iodine-subtracting CT as a diagnostic tool in differentiating between cerebral edema and pseudoedema in CIE.

     

Bergmann’s ossicle (ossiculum terminale persistens): a brief review and differentiation from other findings of the odontoid process

Purpose

The purpose of this paper was to review the literature on Bergmann’s ossicle and provide an overview on its development, etiology, and clinical presentation while also differentiating it from similar structural anomalies.

Methods

A thorough review of the literature available on Bergmann’s ossicle was performed.

Results

Bergmann’s ossicle, also referred to as ossiculum terminale persistens, was defined as a developmental anomaly of the odontoid process in which an ossification center that gives rise to the tip of the dens fails to fuse properly with the body of the axis.

Conclusion

Bergmann’s ossicle is most often a benign condition, although it rarely may present with clinical symptoms such as neck pain and neurological signs. It may be associated with Down’s syndrome and contribute to atlantoaxial instability.

     

Influence of sex,menstrual cycle,and oral contraceptives on the cerebrovascular response to paced deep breathing

Purpose

Deep breathing assesses autonomic function; however, many researchers/clinicians do not account for hyperventilation, brain blood flow or blood pressure.

Methods

Men and women (with/without oral contraceptives) participated. women participated during low and high hormone phases of the menstrual cycle. Blood pressure, end-tidal carbon dioxide, middle cerebral artery velocity and cerebrovascular resistance were assessed.

Results

Deep breathing decreased end-tidal carbon dioxide and middle cerebral artery velocity while increasing cerebrovascular resistance in all participants; blood pressure decreased in men. There were no influences of menstrual cycle or oral contraceptives.

Conclusions

Men have different autonomic responses to deep breathing compared to women.

     

Neurological Adverse Events Associated with Immune Checkpoint Inhibitors: Diagnosis and Management

Purpose of Review

Immune checkpoint inhibitors represent a major step forward in the field of oncologic immunotherapy these last years and have significantly increased survival of cancer patients in an ever-growing number of indications. These agents block specific immune checkpoint molecules (programmed cell death protein 1 and its ligand as well as cytotoxic T-lymphocyte-associated antigen 4) that normally downregulate the immune response. These new agents show a specific range of adverse effects induced by abnormal immunologic activation.

Recent Findings

Many different neurologic adverse events have been described, including encephalitis, myelopathy, aseptic meningitis, meningoradiculitis, Guillain-Barré-like syndrome, peripheral neuropathy (including mononeuropathy, mononeuritis multiplex, and polyneuropathy) as well as myasthenic syndrome.

Summary

Immune checkpoint inhibitors have shown promising results in cancer but can possibly induce autoimmune disorders. Although rare, neurological adverse events require prompt recognition and treatment to avoid substantial morbidity.

     

Interrater Reliability of Pupillary Assessments

Background

Subjective scoring of pupil reactivity is a fundamental element of the neurological examination for which the pupillometer provides an objective measure.

Methods

This single-blinded observational study examined interrater reliability of pupil exam findings between two practitioners and between practitioners and a pupillometer.

Results

From 2329 paired assessments, the interrater reliability between practitioners was only moderate for pupil size (k = 0.54), shape (k = 0.62), and reactivity (k = 0.40). Only 33.3 % of pupils scored as non-reactive by practitioners were scored as non-reactive by pupillometry.

Conclusions

Despite the strong emphasis placed on the traditional pupil examination, especially for patients with a neurological illness, there is limited interrater reliability for subjective scoring of pupillary assessments. Thus, the use of automated pupillometers should be examined as a potential method to increase the reliability of measuring of pupil reactivity.

     

Surgical management of supratentorial ependymomas

Introduction

Supratentorial ependymomas are rare neoplasms accounting for just ten to 15 new cases in the UK per year. This article discusses the surgical management of these tumours.

Materials and methods

We present our experience over the past 12 years looking, in particular, at the location, histological grading, postoperative complications, survival and progression-free survival. A literature review of publications discussing the surgical management of ependymoma over the past 10 years is then presented.

Results

The data shows that complete surgical resection confers a significant survival advantage. There appears to be conflicting data with respect to prognosis when comparing supratentorial to infratentorial ependymoma.

Conclusion

The authors suggest complete excision and advocate, where appropriate, the use of pre and intra-operative functional mapping and second-look surgery. The trade off neurological deficit in the pursuit of complete surgical excision in some instances should be considered.

     

Comparison of Quantitative Characteristics of Early Post-resuscitation EEG Between Asphyxial and Ventricular Fibrillation Cardiac Arrest in Rats

Background

Quantitative electroencephalogram (EEG) analysis has shown promising results in studying brain injury and functional recovery after cardiac arrest (CA). However, whether the quantitative characteristics of EEG, as potential indicators of neurological prognosis, are influenced by CA causes is unknown. The purpose of this study was designed to compare the quantitative characteristics of early post-resuscitation EEG between asphyxial CA (ACA) and ventricular fibrillation CA (VFCA) in rats.

Methods

Thirty-two Sprague–Dawley rats of both sexes were randomized into either ACA or VFCA group. Cardiopulmonary resuscitation was initiated after 5-min untreated CA. Characteristics of early post-resuscitation EEG were compared, and the relationships between quantitative EEG features and neurological outcomes were investigated.

Results

Compared with VFCA, serum level of S100B, neurological deficit score and brain histopathologic damage score were dramatically higher in the ACA group. Quantitative measures of EEG, including onset time of EEG burst, time to normal trace, burst suppression ratio, and information quantity, were significantly lower for CA caused by asphyxia and correlated with the 96-h neurological outcome and survival.

Conclusions

Characteristics of earlier post-resuscitation EEG differed between cardiac and respiratory causes. Quantitative measures of EEG not only predicted neurological outcome and survival, but also have the potential to stratify CA with different causes.

     

Sacral agenesis: evaluation of accompanying pathologies in 38 cases,with analysis of long-term outcomes

Purpose

Sacral agenesis (SA), or caudal regression syndrome, is a congenital malformation of the spine of varying degree of severity. The aim of our study was to identify associated impairments in structure and function of the orthopedic, neurological, cardiopulmonary, genitourinary, and gastrointestinal systems, and to evaluate their impact on function.

Methods

This was a retrospective case series analysis of 38 patients with SA. Patients were divided into two groups: SA with myelomeningocele (group 1) and without myelomeningocele (group 2). Between-group comparisons in terms of the features of the SA, impairments in associated systems, impact on gross motor function, need for surgery, and association with prenatal screening and maternal gestational diabetes were evaluated.

Results

The majority of comorbidities were orthopedic and neurological in nature. Impairments in sphincter control and independent transferring were more prevalent in group 1, resulting in lower function. Scoliosis, kyphosis, and hip dislocation/subluxation were the most common orthopedic problems, with a higher prevalence of kyphosis in group 1. The requirement for neurosurgery was significantly higher in group 1.

Conclusions

Orthopedic and neurological comorbidities are commonly associated with SA and are more prevalent in the presence of a myelomeningocele. As the impairments impact a child’s ability for maximum function, early identification and intervention is required to correct or ameliorate the impairment.Level of Evidence: Level IV.

     

Musik- und Sprachwahrnehmung bei Epilepsiepatienten

Background

Language and music present numerous structural similarities. This suggests that both domains may be built on shared cognitive and neuroanatomical resources.

Objectives

Here, discrepant results that either support or deny neurocognitive links between language and music are discussed. It is argued that the investigation of cognitive subprocesses and the consideration of neuropathology can reconcile the conflicting findings.

Methods

Language–music links were tested in patients with temporal lobe epilepsy (TLE) by means of electrocorticography (study I) and functional magnetic resonance imaging (study II), with specific focus on grammar processing and memory building.

Results

Study I showed a co-localization of grammar processing in language and music in bilateral temporal lobes. Study II yielded an atypical segregation of text and melody in song memory in patients with left TLE.

Conclusions

These results lend evidence for neurocognitive links between language and music. Yet, they demonstrate the importance to focus on cognitive subprocesses and to take the neurological health of participants into account.

     

Pathogenesis of cerebral palsy through the prism of immune regulation of nervous tissue homeostasis<Emphasis Type="Bold">:</Emphasis> literature review

Background

The cerebral palsy is highly actual issue of pediatrics, causing significant neurological disability. Though the great progress in the neuroscience has been recently achieved, the pathogenesis of cerebral palsy is still poorly understood.

Methods

In this work, we reviewed available experimental and clinical data concerning the role of immune cells in pathogenesis of cerebral palsy. Maintaining of homeostasis in nervous tissue and its transformation in case of periventricular leukomalacia were analyzed.

Results

The reviewed data demonstrate involvement of immune regulatory cells in the formation of nervous tissue imbalance and chronicity of inborn brain damage. The supported opinion, that periventricular leukomalacia is not a static phenomenon, but developing process, encourages our optimism about the possibility of its correction.

Conclusions

The further studies of changes of the nervous and immune systems in cerebral palsy are needed to create fundamentally new directions of the specific therapy and individual schemes of rehabilitation.

     

Takotsubo Syndrome: Clinical Features,Pathogenesis, Treatment,and Relationship with Cerebrovascular Diseases

Purpose of Review

This review paper aims to provide a complete and updated overview on the clinical and pathophysiological aspects of Takotsubo syndrome (TTS), including prognosis, therapy, and the association with cerebrovascular conditions.

Recent Findings

TTS is an increasingly recognized non-ischemic cardiomyopathy characterized by sudden, temporary weakening of the myocardium, of which the pathogenesis is unknown.

Summary

Although pathogenesis of TTS remains unclear, a complex interaction between catecholamine-mediated stimulation, myocardial stunning, and subsequent stress-related myocardial dysfunction seems to be the main pathophysiological mechanism. Stroke is linked to TTS by a dual relationship since it may induce TTS by catecholamine release even if TTS itself also may be complicated by left ventricular thrombi leading to stroke. Given its possible complications, including the association with neurological diseases, both cardiologist and neurologists should be aware about TTS in order to diagnose it promptly and to initiate appropriate therapeutic measures.

     

Neurovascular stents in pediatric population

Purpose

The purpose of the study is to analyze the results obtained using stents for the treatment of neurovascular diseases in pediatric patients.

Methods

A retrospective study of 6-year period was undertaken evaluating clinical charts and imaging studies of patients treated with stents because of neurovascular diseases.

Results

Nine patients were managed with 10 stents. Seven children were females. The median age was 11 years. There were four cases of broad neck cerebral aneurysms, a pseudoaneurysm of the cervical internal carotid artery, a vertebro-jugular fistula, two patients with internal carotid artery (ICA) stenosis affecting the cervical and supraclinoid segment, and a vertebral artery dissection. The only complication was a silent posterior communicating artery (PCoA) thrombosis in a PCoA aneurysm treated with two stents. Dual antiplatelet therapy was given after the procedure to avoid in stent thrombosis.

Conclusion

Stents are safe and effective for treatment of neurovascular diseases in children, but studies are needed in order to protocolize the use of antiplatelet drugs in children.

     

„Mission (im)possible“

Background

Specialized neurological treatment decreases the mortality and morbidity of stroke patients. In many regions of the world an extensive coverage is not available. The cooperation between the Krankenhaus Nordwest (KHNW, Frankfurt, Germany) and the Government of Brunei Darussalam describes the set-up process of a specialized neurological center, including stroke unit, science and rehabilitation center.

Aim

The aim of this project called to teach to treat – to treat to teach was to set up a center of excellence in neurology in Brunei Darussalam over a distance of 12,000?km. Treatment options were elucidated by teaching and taught by case examples.

Material and methods

The construction of the Brunei Neuroscience Stroke and Rehabilitation Center (BNSRC) began in July 2010. To overcome the large distance between the department of neurology and neuroradiology at the KHNW and the BNSRC, a telemedical network was established. We provided daily teleteaching for all professions involved in patient care as well as 24/7 availability of teleneurological services from Germany to support the local team on site.

Results

In the BNSRC unit over 1000 patients with ischemic and hemorrhagic stroke and all the various acute neurological conditions were treated from July 2010 until July 2016 as inpatients and over 5000 were treated as outpatients. Since 2010, a total of 52 patients with stroke were treated by thrombolysis within the thrombolytic window and 81 hemicraniectomies were performed.

Conclusion

The project has shown that it is possible to convey specialized neurological knowledge over large distances to provide significant benefits for patients and caregivers.

     

Deutschlandweite Evaluation der ärztlichen Weiterbildung in der klinischen Neurologie

Background

Currently, no data are available, which reflect the situation of medical doctors specializing in neurology in German hospitals. In order to secure the high standard of neurological patient care it is essential to evaluate the working conditions and the specialty training in neurology.

Objective

This nationwide survey was conducted throughout Germany with the aim to address problems and to give suggestions for improvements in neurological training curricula.

Material and methods

The survey was online from February to May 2017 and 953 neurologists undergoing further training participated.

Results

More than half of the young neurologists were satisfied with their medical training. One of the main problems that complicates clinical training is the workload. In addition, organizational obstacles within the clinic, such as poor structure of education or a lack of mentors, lead to dissatisfaction among participants. The size or type of the department, as well as the prevailing service system, exert only a minor influence on the quality of specialist training, although there were differences especially in the self-assessment of the participants in connection with the type of department (university hospital versus public or private hospital).

Conclusion

Specialist training in neurology can be improved by simple arrangements, e.?g., the introduction of a binding rotation scheme, internal mentoring and structured feedback. In addition, it will be necessary to relieve medical staff of administrative duties in order to create time for training and the learning of competencies.

     

Traumatic atlanto-occipital dislocation: do children and adolescents have better or worse outcomes than adults? A narrative review

Background

Traumatic atlanto-occipital dislocation is an uncommon, severely unstable pathology, which can lead to detrimental or even fatal neurological impairment. Specifically, children have consistently been reported to be more susceptible to this type of injury because of their disproportionately larger head, ligament laxity, and injury mechanisms. However, to date, rates of missed injury and outcomes including neurologic recovery of pediatric and adult populations following this insult have not been comparatively evaluated.

Methods

Standard search engines were used to investigate outcomes of traumatic atlanto-occipital dislocation in children and adolescents compared to adults.

Conclusions

Based on case reports and small series from the literature, it seems that children and adolescents tend to have a better likelihood of survival with the possibility of long-term neurological complications. Comparatively, adults who suffer traumatic atlanto-occipital dislocation either succumb to their injuries or survive with very little if any neurological complications.

     

Neuromuscular Complications of Programmed Cell Death-1 (PD-1) Inhibitors

Purpose of Review

In recent years, immune checkpoint inhibitors have been increasingly used in patients with metastatic cancers with favorable oncological outcomes; however, there have also been increasing number of cancer survivors who have developed immune-related adverse events. Little is known about PD-1 inhibitor-associated neuromuscular complications.

Recent Findings

Neuromuscular disorders are the most common neurological complication reported in PD-1 inhibitor-treated patients. Myasthenia gravis, immune-mediated myopathies, and Guillain-Barre syndrome are among commonly reported immune-related neuromuscular complications. HyperCKemia occurs frequently in patients with PD-1 inhibitor-associated myasthenia gravis, indicating coexisting myopathies or myocarditis. Oculobulbar weakness is a unique and common presentation of PD-1 inhibitor-associated immune-mediated myopathies with or without concomitant myasthenia gravis. High-dose steroid monotherapy may be associated with clinical deterioration in some patients with PD-1 inhibitor-associated myasthenia gravis, immune-mediated myopathies, or Guillain-Barre syndrome.

Summary

PD-1 inhibitor-associated neuromuscular complications have some characteristic features compared to their idiopathic counterparts. Although steroid monotherapy is commonly used in non-neuromuscular autoimmune disorders triggered by anti-PD-1 therapy, this may lead to unfavorable outcomes in some patients with PD-1 inhibitor-associated neuromuscular complications.

     

Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis

Background

Chronic pain patients increasingly seek treatment through mindfulness meditation.

Purpose

This study aims to synthesize evidence on efficacy and safety of mindfulness meditation interventions for the treatment of chronic pain in adults.

Method

We conducted a systematic review on randomized controlled trials (RCTs) with meta-analyses using the Hartung-Knapp-Sidik-Jonkman method for random-effects models. Quality of evidence was assessed using the GRADE approach. Outcomes included pain, depression, quality of life, and analgesic use.

Results

Thirty-eight RCTs met inclusion criteria; seven reported on safety. We found low-quality evidence that mindfulness meditation is associated with a small decrease in pain compared with all types of controls in 30 RCTs. Statistically significant effects were also found for depression symptoms and quality of life.

Conclusions

While mindfulness meditation improves pain and depression symptoms and quality of life, additional well-designed, rigorous, and large-scale RCTs are needed to decisively provide estimates of the efficacy of mindfulness meditation for chronic pain.

     

Perceptions of Neighborhood Park Quality: Associations with Physical Activity and Body Mass Index

Background

Parks are important resources for physical activity (PA), yet few studies have examined how perceptions of park characteristics relate to PA and health.

Purpose

This study investigated associations between perceptions of neighborhood park quality and overall moderate-to-vigorous PA (MVPA), park-based PA, and body mass index (BMI).

Methods

Data were collected via questionnaire from 893 households in Kansas City, Missouri.

Results

The newly developed neighborhood park quality scale demonstrated good test–retest and internal reliability. Residents’ perceptions of neighborhood park quality were related to PA and health outcomes. Perceiving parks as a benefit was positively related to overall MVPA and park-based PA and negatively related to BMI. Perceptions of well-used parks were positively related to BMI, while perceived cleanliness was negatively related to park-based PA.

Conclusions

Better measuring and understanding how perceptions of local parks are associated with PA and health can improve appreciation of how parks facilitate active living.

     

Devastating Delayed Leukoencephalopathy Associated with Bath Salt Inhalation

Background

“Bath salts” or synthetic cathinone toxicity remains a potentially deadly clinical condition. We report a delayed leukoencephalopathy with persistent minimally conscious state.

Methods

Case report.

Results

A 36-year-old man presents with delayed encephalopathy, dysautonomia, fulminant hepatic failure, and renal failure from severe rhabdomyolysis after consuming bath salts. MRI showed diffusion restriction in the splenium of the corpus callosum and subcortical white matter.

Conclusions

The combination of acute leukoencephalopathy, rhabdomyolysis and fulminant hepatic failure may point to bath salt inhalation and should be known to neurointensivists.

     

Autonomic symptoms following Zika virus infection

Purpose

To determine if autonomic symptoms are associated with previous Zika virus infection.

Methods

Case–control study including 35 patients with Zika virus infection without evidence of neurological disease and 105 controls. Symptoms of autonomic dysfunction were assessed with the composite autonomic symptom scale 31 (COMPASS-31).

Results

Patients with previous Zika virus infection had significantly higher COMPASS-31 score than controls regardless of age and sex (p = 0.007). The main drivers for the higher scores where orthostatic intolerance (p = 0.003), secretomotor (p = 0.04) and bladder symptoms (p < 0.001).

Conclusion

Zika virus infection is associated with autonomic dysfunction. The mechanisms remain to be elucidated.