Diffusion- and perfusion-weighted MRI in a patient with a prolonged reversible ischaemic neurological deficit

We report acute and follow-up diffusion- and perfusion-weighted MRI (DWI, PWI) findings in a patient with a prolonged reversible ischaemic neurological deficit. PWI 12 h after the patient was last seen to be without symptoms revealed a large perfusion deficit in the left posterior MCA territory with a relatively inconspicuous and much smaller abnormality on DWI. Follow-up showed resolution of abnormalities on both DWI and PWI, and conventional MRI was normal, apart from a very slight abnormality, visible only on FLAIR images, at the centre of the initially DWI-positive region. These findings demonstrate the utility of PWI when be used in combination with DWI to investigate the pathophysiology of transient ischemic syndromes. Received: 26 July 1999/Accepted: 20 September 1999     

Bilateral common carotid occlusion without neurological deficit

A 40-year-old man presented with pain and numbness in his right arm. On his clinical examination, no neurological deficit was found. Bilateral common carotid artery duplex sonography scan demonstrated no flow in either lumen. No abnormality was recognized on brain CT. On cerebral digital substraction angiogram, total occlusion of the brachiocephalic trunk and left carotid artery were shown. There was a modest stenosis in the left vertebral artery. Collateral circulation feeding the intracranial carotid system mainly originated from the left vertebrobasilar system. Previous cases of bilateral carotid occlusion are reviewed and discussed.     

Gunshot injury to the face with a missile lodged in the upper cervical spine without neurological deficit

An unusual case of facial gunshot injury with the missile lodged in the cervical spinal canal, but without any neurological impairment is reported. The extent of tissue damage and missile track termination in a male patient who sustained gunshot trauma to the face was assessed by plain radiography and by CT scans. The patient was treated conservatively and observed for clinical manifestations of neurological deficit for 3 weeks. CT of the head and neck performed 13 years after injury with the three-dimensional (3D) reconstruction of skeletal elements revealed healed fractures of the right nasal bone, the labyrinth of the right ethmoid bone, and position of the missile on the medial aspect of the right lateral mass of the atlas. There was no migration of the missile during this period. This case report of gunshot wound to the face associated with injury of the cervical spine indicated possibility of survival and atypical absence of clinical manifestation that may occur even when a bullet remains in the spinal canal.     

Vertebroplasty in the treatment of symptomatic vertebral haemangiomas without neurological deficit

Objective

To evaluate the effectiveness of vertebroplasty in symptomatic vertebral haemangiomas (VHs) with no neurological deficit, with or without features of aggressiveness in imaging studies.

Methods

A retrospective study was conducted to review 31 consecutive patients with symptomatic VHs that underwent vertebroplasty procedures (13 males, 18 females; mean age, 57.5 years), for a total of 33 affected vertebral levels (range, T4–L5 levels). Pre procedure radiological examinations were reviewed. The presence of predominant soft tissue stroma on CT, low signals on T1W of MRI, epidural tissue, and cortical erosion are considered features of aggressiveness. The clinical effects were evaluated using the visual analogue scale (VAS) and modified Roland–Morris Disability Questionnaire (RDQ) at the pre and each postoperative follow-up time point (mean follow-up of 15.8 months).

Results

Symptomatic VHs with no signs of aggressiveness were observed in 26 lesions and those with signs of aggressiveness in 7 lesions. Vertebroplasty was successfully performed under fluoroscopic guidance with a unipedicular approach in 16 levels, a bipedicular approach in 17 levels. VAS scores and RDQ scores were significantly improved after vertebroplasty (P?<?0.001). Extraosseous cement leakage was observed in 4 patients without clinical complications.

Conclusions

Vertebroplasty is an optional treatment for symptomatic VHs with no neurological deficit.

Key Points

? Vertebral haemangiomas with or without aggressive signs may cause pain. ? Radiological signs of aggressiveness include evidence of lesions that contain less fat predominance, evidence of epidural soft tissue and evidence of cortical erosion. ? Vertebroplasty provides effective treatment for symptomatic vertebral haemangiomas causing no neurological deficit.     

短暂头痛、神经功能缺损伴脑脊液淋巴细胞增多综合征病例综述

短暂头痛、神经功能缺损伴脑脊液淋巴细胞增多综合征是一种表现为发作性头痛、短暂神经功能缺损、脑脊液淋巴细胞增多且反复发作的神经综合征.该综合征临床缺乏特异性,易与短暂性脑缺血发作、颅内肿瘤、病毒性脑炎、偏头痛等疾病混淆,所以其初次诊断的准确率低,容易漏诊,迄今国内仅见1例报道.为提高对此综合征的认识,本文对其病因、临床特征、诊治进展进行综述.     

Prediction of delayed neurological deficit after subarachnoid haemorrhage: a CT blood load and Doppler velocity approach

The predictive value of cranial computed tomography (CT) blood load and serial transcranial Doppler sonography for the development of delayed ischaemic neurological deficit was assessed in 121 patients following subarachnoid haemorrhage. Of the 121 patients, 81 (67%) had thick layers of blood or haematoma, including intraventricular bleeding. The proportion of patients who developed delayed deficit was higher with increasing amounts of subarachnoid blood on the admission CT (51% of 53 cases in Fisher grade 3; 35% of 33 cases in grade 2; 28% of 7 cases in grade 1,P<0.01). Doppler velocities obtained from readings at least every 2 days following admission were higher in patients with delayed neurological deficit (peak velocity for grade 3 patients 176±6 cm/s (mean±SE), versus grade 2: 164±7 cm/s; grade 4 149±9, bothP=0.04, Mann-Whitney). Peak velocity and maximal 24-h rise tended to be higher within different CT grades in patients with a deficit than in those without; this difference was significant for grade 3 patients (P<0.01). We conclude that a combined approach with CT and Doppler sonography provides greater predictive value for the development of delayed ischaemic neurological deficit than either test considered independently. The value of Doppler sonography may be greatest for patients with Fisher grade 3 blood, in whom the risk of delayed ischaemia is greatest.     

The association between neurological deficit in acute ischemic stroke and mean transit time

The purpose of our study was to identify the perfusion MRI (pMRI) algorithm which yields a volume of hypoperfused tissue that best correlates with the acute clinical deficit as quantified by the NIH Stroke Scale (NIHSS) and therefore reflects critically hypoperfused tissue. A group of 20 patients with a first acute stroke and stroke MRI within 24 h of symptom onset were retrospectively analyzed. Perfusion maps were derived using four different algorithms to estimate relative mean transit time (rMTT): (1) cerebral blood flow (CBF) arterial input function (AIF)/singular voxel decomposition (SVD); (2) area peak; (3) time to peak (TTP); and (4) first moment method. Lesion volumes based on five different MTT thresholds relative to contralateral brain were compared with each other and correlated with NIHSS score. The first moment method had the highest correlation with NIHSS (r=0.79, P<0.001) followed by the AIF/SVD method, both of which did not differ significantly from each other with regard to lesion volumes. TTP and area peak derived both volumes, which correlated poorly or only moderately with NIHSS scores. Data from our pilot study suggest that the first moment and the AIF/SVD method have advantages over the other algorithms in identifying the pMRI lesion volume that best reflects clinical severity. At present there seems to be no need for extensive postprocessing and arbitrarily defined delay thresholds in pMRI as the simple qualitative approach with a first moment algorithm is equally accurate. Larger sample sizes which allow comparison between imaging and clinical outcomes are needed to refine the choice of best perfusion parameter in pMRI.     

手术与非手术治疗无神经损伤胸腰椎爆裂骨折的Meta分析

目的 对无神经损伤胸腰椎爆裂骨折手术与非手术治疗进行Meta分析及疗效比较.方法 由2名研究者独立检索Pubmed Medline、荷兰医学文摘数据库(Embase)、Cochrane系统综述数据库和临床对照试验数据库、中国生物医学文献数据库(CBM)、万方数据库、中国知网(CNKI).根据纳入、排除标准筛选各数据库建库至2014年2月发表的文献,并遵循Cochrane指南进行文献质量评价及数据提取. 结果 最终纳入2篇随机对照研究,获取79例患者的临床资料(手术组41例,非手术组38例)进行Meta分析,随访期限最少2年.2篇研究的异质性较大,其中1篇认为随访结束时手术组在疼痛缓解、功能恢复及重返工作方面疗效较好;而另1篇的结果则相反.Meta结果显示,手术组并发症(RR =2.85,95％ CI 0.83 ～9.75)包括再次手术率(RR=8.39,95％CI 1.12 ～62.87)较高. 结论 对于无神经损伤的胸腰椎爆裂骨折,手术与非手术治疗在缓解疼痛、促进功能恢复及患者重返工作方面疗效相似,手术治疗往往带来较多的并发症.     

超早期脑梗死溶栓治疗联合应用依达拉奉后神经功能缺损症状的临床观察

目的观察超早期脑梗死溶栓治疗联合应用新型自由基清除剂依达拉奉的神经功能缺损症状情况。方法选择69例入我院的超早期脑梗死患者,随机分为重组组织型纤溶酶原激活剂（rt-PA）溶栓联合自由基清除剂依达拉奉治疗组（35例）和单独使用rt-PA溶栓治疗组（34例）,比较治疗15 d、30 d和90 d时的美国国立卫生院卒中量表评分（NIHSS）。结果联合溶栓组治疗后15 d时NIHSS评分0-1分28.6%（10/35）与单纯溶栓组17.6%（6/34）比较有统计学意义（P〈0.05）;30 d时分别为34.3%（12/35）和23.5%（8/34）,比较有显著性意义（P〈0.05）;90 d时分别为42.9%（15/35）和23.5%（8/34）,比较有也显著性意义（P〈0.05）。两组15 d、30 d和90 d的疗效差异有统计学意义。结论超早期脑梗死溶栓治疗联合应用新型自由基清除剂依达拉奉的能够更有效地改善病人的神经功能缺损症状。     

切口内使用氨甲环酸对早期手术治疗伴神经损伤的胸腰椎爆裂骨折失血量的影响

目的探讨切口内使用氨甲环酸(TXA)对早期手术治疗伴神经损伤的胸腰椎爆裂骨折(TBF)患者的安全性和有效性。方法前瞻性纳入2015年6月—2019年6月重庆医科大学附属第一医院收治的伴神经损伤TBF患者59例,男性34例,女性25例;年龄35~63岁,平均46.9岁。患者均接受后路减压骨折复位内固定术,使用随机数字表法分为TXA组(30例)和生理盐水组(29例)。在切皮暴露后30例患者切口处浸泡100mL TXA溶液(1g)5min(TXA组);29例患者浸泡相同体积生理盐水5min(生理盐水组)。收集两组患者一般资料、总失血量、显性失血量、隐性失血量、术中失血量及引流量;同时检测患者术前,术后第1、3天红细胞浓度(Hgb)及红细胞压积(Hct),并记录每组输血例数、下地时间、住院时间及药物相关并发症。结果TXA组手术时间较生理盐水组显著减少(110.67±12.95)min vs.(135.14±15.68)min,P<0.05。失血量分析发现TXA组术后总失血量(942.11±49.03)mL vs.(1192.20±51.94)mL、显性失血量(514.92±68.54)mL vs.(754.57±59.43)mL、术中失血量(250.45±60.35)mL vs.(364.73±52.17)mL及术后引流量(170.46±25.04)mL vs.(312.36±46.53)mL均较生理盐水组显著降低(P<0.05),但两组患者隐性失血量(428.19±35.44)mL vs.(437.63±39.28)mL差异无统计学意义(P>0.05)。术后第1、3天TXA组Hgb(123.51±10.36)g/L、(120.39±12.35)g/L显著高于生理盐水组(109.43±11.69)g/L、(107.59±9.38)g/L,因此输血例数TXA组显著减少(1/30 vs.5/29)(P<0.05),但两组患者Hct差异无统计学意义(36.04±5.39)%vs.(36.18±5.57)%、(35.86±4.43)%vs.(35.91±4.69)%,P>0.05。同时,TXA组下地时间、住院时间(2.31±0.79)d、(5.43±1.48)d较生理盐水组(4.45±1.24)d、(8.15±2.05)d显著缩短(P<0.05),两组患者均未发现药物相关不良反应。结论本研究初步证实切口内使用TXA对于伴神经损伤TBF早期手术患者具有良好的安全性与有效性。     

Going high with preexisting neurological conditions

This review presents the potential impact of high altitude exposure on preexisting neurological conditions in patients usually living at low altitude. The neurological conditions include permanent and transient ischemia of the brain, occlusive cerebral artery disease, cerebral venous thrombosis, intracranial hemorrhage and vascular malformations, multiple sclerosis, intracranial space-occupying lesions, dementia, extrapyramidal disorders, migraine and other headaches, and epileptic seizures. New developments in diagnostic work-up and treatment of preexisting neurological conditions are also mentioned where applicable. For each neurological disorder, the authors developed absolute and relative contraindications for a trip to high altitude. These recommendations are not based on the results of controlled randomized trials, but mainly on case reports, pathophysiological considerations, and extrapolations from the low altitude situation.     

Global cerebral hypoperfusion in a patient with transient global amnesia

We report a 64-year-old male patient with pure transient global amnesia (TGA) who exhibited global cerebral hypoperfusion during an amnesia attack. Initial single photon emission computed tomography (SPECT) performed 3 hours after the onset of the amnesic attack revealed diffuse hypoperfusion in the cerebrum, whereas a second SPECT study, 1 month later, revealed improvement of cerebral blood flow. This case suggests that SPECT study is useful in revealing the pathophysiological mechanism of TGA and that TGA attacks are associated with global cerebral blood flow change.     

Rheumatoid cervical luxations with fatal neurological complications

Summary When the cervical spine is involved in primary chronic polyarthritis, this leads in 6–8% of cases to an atlantoaxial dislocation or to luxations in the subaxial region. This may in turn lead to spinal cord compression and to an intermittent vertebral artery insufficiency. The clinical and radiological findings are described in 4 cases and the symptomatology discussed with the aid of the literature. The recognition of such complications in primary chronic polyarthritis is important, since neurosurgical measures for the stabilization of the cervical spine can produce impressive remissions.

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Rheumatische Halswirbelsäulen-Luxation mit gefährlichen neurologischen Komplikationen

Zusammenfassung Der Befall der Halswirbelsäule bei der primär-chronischen Polyarthritis führt in 6–8% zum Auftreten einer atlantoaxialen Dislokation bzw. zu Luxationen im subaxialen Bereich. Dadurch bedingt kann es zum Auftreten von Rückenmarkskompressionen und einer intermittierenden A. vertebralis-Insuffizienz kommen. Anhand von 4 Fällen wird der klinische und röntgenologische Befund aufgezeichnet und das Krankheitsbild anhand der Literatur diskutiert. Die Kenntnis derartiger Komplikationen bei der primärchronischen Polyarthritis ist wichtig, da neurochirurgische Maßnahmen mit Stabilisierung der Halswirbelsäule zu eindrucksvollen Remissionen führen können.

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Luxations cervicales rhumatoïdes avec complication neurologique fatale

Résumé La polyarthrite chronique primitive du rachis cervical entraîne dans 6 à 8% des cas une dislocation atlanto-axiale ou des luxations dans la régions sous-axiale. Ceci peut conduire à des compressions médullaires et à une insuffisance intermittente de l'artère vertébrale. Les données cliniques et radiologiques sont décrites dans quatre cas et la symptomatologie est discutée comptetenu de la littérature. Il est important de reconnaître de telles complications en cas de polyarthrite chronique primitive puisque des procédés neurochirurgicaux de stabilisation du rachis cervical peuvent apporter des rémissions impressionnantes.

     

‘Luxury perfusion syndrome’ in a patient with reversible ischemic neurological deficits

A 28-year-old man was admitted to the hospital with difficulty in speech and motor weakness of the right arm of sudden onset. Twelve years previously a grade I oligodendroglioma had been removed. The CT scan showed a low density area without enhancement in the left frontal region that appeared to communicate with the left lateral ventricle. An increased flow through the left middle cerebralartery and a focal avascular area in the left hemisphere was noted during a dynamic study by angioscintigraphy. A radionuclide cerebral control study showed reduced flow through the left middle cerebral artery. The patient was discharged 25 days after admission with the diagnosis of (1) reversible ischemic neurological deficits associated a hyperperfusion and (2) porencephaly.     

Dorsiflexion deficit during jogging with chronic ankle instability

The purpose of the study was to determine whether individuals with chronic ankle instability (CAI) demonstrate altered dorsiflexion/plantar flexion range of motion (ROM) compared to controls during jogging. The case control study took place in a university motion analysis laboratory. Fourteen volunteers participated in the study, seven suffered from CAI (age 25 ± 4.2 years, height 173 ± 9.4 cm, mass 71 ± 8.1 kg) and seven were healthy, matched controls (age 25 ± 4.5 years, height 168 ± 5.9 cm, mass 67 ± 9.8 kg). All subjects jogged on an instrumented treadmill while a ten-camera motion analysis system collected three-dimensional kinematics of the lower extremities. The main outcome measure was sagittal plane (dorsiflexion/plantar flexion) range of motion of the ankle throughout the gait cycle. CAI subjects had significantly less dorsiflexion compared to the control group from 9% to 25% during jogging (4.83 ± 0.55°). CAI subjects demonstrated limited ankle dorsiflexion ROM during the time of maximal dorsiflexion during jogging. Limited dorsiflexion ROM during gait among individuals with CAI may be a risk factor for recurrent ankle sprains. These deficits should be treated appropriately by rehabilitation clinicians.