Late recovery of awareness in prolonged disorders of consciousness –a cross-sectional cohort study

Purpose: To detect any improvement of awareness in prolonged disorders of consciousness in the long term.

Methods: A total of 34 patients with prolonged disorders of consciousness (27 vegetative state and seven minimally conscious state; 16 males; aged 21–73) were included in the study. All patients were initially diagnosed with vegetative/minimally conscious state on admission to our specialist neurological rehabilitation unit. Re-assessment was performed 2–16?years later using Coma Recovery Scale-Revised.

Results: Although remaining severely disabled, 32% of the patients showed late improvement of awareness evidenced with development of non-reflexive responses such as reproducible command following and localization behaviors. Most of the late recoveries occurred in patients with subarachnoid hemorrhage (5/11, 45.5%). The ages of patients within the late recovery group (Mean?=?45, SD?=?11.4) and non-recovery group (Mean?=?43, SD?=?15.5) were not statistically different (p?=?0.76).

Conclusions: This study shows that late improvements in awareness are not exceptional in non-traumatic prolonged disorders of consciousness cases. It highlights the importance of long-term follow up of patients with prolonged disorders of consciousness, regardless of the etiology, age, and time passed since the brain injury. Long-term follow up will help clinicians to identify patients who may benefit from further assessment and rehabilitation. Although only one patient achieved recovery of function, recovery of awareness may have important ethical implications especially where withdrawal of artificial nutrition and hydration is considered.

• Implications for rehabilitation

• Long-term regular follow-up of people with prolonged disorders of consciousness is important.

• Albeit with poor functional outcomes late recovery of awareness is possible in both traumatic and non-traumatic prolonged disorders of consciousness cases.

• Recovery of awareness has significant clinical and ethical implications especially where withdrawal of artificial nutrition and hydration is considered.

     

Assessment of cardiac autonomic functions by heart rate recovery,heart rate variability and QT dynamicity parameters in patients with acromegaly

Cardiovascular complications are the most common causes of morbidity and mortality in acromegaly. However, there is little data regarding cardiac autonomic functions in these patients. Herein, we aimed to investigate several parameters of cardiac autonomic functions in patients with acromegaly compared to healthy subjects. We enrolled 20 newly diagnosed acromegalic patients (55 % female, age:45.7 ± 12.6 years) and 32 age- and gender-matched healthy subjects. All participants underwent 24 h Holter recording. Heart rate recovery (HRR) indices were calculated by subtracting 1st, 2nd and 3rd minute heart rates from maximal heart rate. All patients underwent heart rate variability (HRV) and QT dynamicity analysis. Baseline characteristics were similar except diabetes mellitus and hypertension among groups. Mean HRR1 (29.2 ± 12.3 vs 42.6 ± 6.5, p = 0.001), HRR2 (43.5 ± 15.6 vs 61.1 ± 10.8, p = 0.001) and HRR3 (46.4 ± 16.2 vs 65.8 ± 9.8, p = 0.001) values were significantly higher in control group. HRV parameters as, SDNN [standard deviation of all NN intervals] (p = 0.001), SDANN [SD of the 5 min mean RR intervals] (p = 0.001), RMSSD [root square of successive differences in RR interval] (p = 0.001), PNN50 [proportion of differences in successive NN intervals >50 ms] (p = 0.001) and high-frequency [HF] (p = 0.001) were significantly decreased in patients with acromegaly; but low frequency [LF] (p = 0.046) and LF/HF (p = 0.001) were significantly higher in acromegaly patients. QTec (p = 0.009), QTac/RR slope (p = 0.017) and QTec/RR slope (p = 0.01) were significantly higher in patients with acromegaly. Additionally, there were significant negative correlation of disease duration with HRR2, HRR3, SDNN, PNN50, RMSSD, variability index. Our study results suggest that cardiac autonomic functions are impaired in patients with acromegaly. Further large scale studies are needed to exhibit the prognostic significance of impaired autonomic functions in patients with acromegaly.     

Early-mid term follow-up results of percutaneous closure of the interatrial septal defects with occlutech figulla devices: a single center experience

Background: Percutaneous closure of secundum type atrial septal defect (ASD) and patent foramen ovale (PFO) has gained widespread use in recent years. Herein, we evaluated the safety and efficacy of the Occlutech® Figulla devices for PFO and ASD closure in a reference tertiary center. Methods: All 143 patients (46.9% male, mean age 39.3 ± 12.2 years) who underwent transcatheter PFO (n = 85) and ASD (n = 58) closure with Occlutech® Figulla devices between February 2009 and October 2011 were included in this study. An echocardiographic follow‐up examination was performed at the 1st, 6th, and 12th month visits. Results: The devices were successfully implanted in all 143 patients (100%). In‐hospital periprocedural complications were device embolization (0.7%; 1 ASD patient), atrial fibrillation (1.4%; 1 ASD and 1 PFO patients), supraventricular tachycardia (0.7%; 1 PFO patient), and vascular access hematoma (0.7%; 1 ASD patient). Among ASD patients, 2 patients had trivial (jet width <1 mm in diameter) and 1 patient had small (1–2 mm) residual shunts before hospital discharge, which disappeared after the 6‐month visit. During the mean 15.4 ± 9.6 months follow‐up, all patients were asymptomatic and no ischemic stroke, cardiac perforation, device erosion, embolization, thrombus formation, or malposition of the device was observed. Conclusions: Percutaneous PFO and secundum type ASD closure with the novel Occlutech® Figulla Occluder devices without left atrial central pin and with significantly reduced meshwork was safe, feasible, and effective. (J Interven Cardiol 2012;25:375–381)     

Early Myocardial Functional Alterations in Patients with Obstructive Sleep Apnea Syndrome

Background: There is limited information regarding myocardial alterations in patients with obstructive sleep apnea syndrome (OSAS) in the absence of pulmonary and cardiac comorbidity. In this study, we aimed to evaluate potential myocardial alterations of these patients and investigate the possible effects of OSAS-related pathological variations on left and right ventricular functions. Methods: We studied 107 consecutive patients who were referred to our sleep laboratory for clinically suspected OSAS and 30 controls without any history or symptoms of sleep-related disorders. Severity of OSAS was quantified by polysomnography. Patients with apnea–hypopnea index (AHI) < 5 were included in the OSAS (−) group (Group 1, n = 22). Subjects with AHI ≥ 5 were considered as OSAS and classified according to their AHI as mild-to-moderate (AHI ≥ 5 and AHI < 30) (Group 2, n = 45) and severe (AHI ≥ 30) OSAS groups (Group 3, n = 40). Conventional M-mode, 2D, and Doppler mitral inflow parameters, tissue Doppler velocities, myocardial peak systolic strain, and strain rate values of various segments were measured and compared between groups. Results: Patients with OSAS displayed impairment of left ventricular diastolic function compared with controls. There were no significant differences between groups regarding parameters reflecting left ventricular systolic function. Myocardial strain analysis demonstrated significant decrement regarding apical right ventricular longitudinal peak systolic strain and strain rate values between groups in relation to the severity of OSAS. Conclusions: Patients with OSAS display a regional pattern of right ventricular dysfunction correlated with the severity of disease.     

Cervical syringohydromyelia secondary to chronic supratentorial subdural hematoma

Introduction: Syringohydromyelia associated with supratentorial space-occupying lesion has rarely been reported. We present a 28-year-old woman was admitted to the hospital with head and neck pain. Upon examination, there was only left central facial paralisia, with no evidence of papilledema. Methods and Results: Cranial magnetic resonance imaging (MRI) revealed a left parietal and temporal chronic subdural hematoma (CSH) with a 1-cm shift to the right from midline. Also, cervical MRI revealed a syringohydromyelic cavity at the level of C6/7. The patient was operated on for supratentorial CSH. A follow-up cervical MRI revealed no syringohydromyelic cavity after 2 months. No neurological deficit was reported, and overall outcome was excellent. Conclusion: Syringohydromyelia was secondary to a space-occupying lesion in our case of supratentorial chronic subdural hematoma.     

Transient focal cerebral ischemia-induced neurogenesis in the dentate gyrus of the adult mouse

OBJECT: Throughout the life of a mammal, new neurons are produced each day from resident progenitor cells located in the hippocampal dentate gyrus (DG). The availability of transgenic and knockout mice enables the evaluation of specific molecular mediators of this phenomenon. To facilitate such studies the authors characterized the proliferation, survival, and maturation of progenitor cells in the DG of adult mice following transient focal cerebral ischemia. METHODS: Anesthesia was induced in adult C57BL/6 mice by administering halothane. The middle cerebral artery (MCA) was then occluded for 120 minutes by applying an endovascular suture. The marker used to detect the presence of proliferating cells, 5-bromodeoxyuridine (BrdU; 50 mg/kg) was administered intraperitoneally twice daily on Days 2 through 6 after the MCA occlusion. Cohorts of mice were killed on Days 7 and 21, after which their brains were sectioned and BrdU-positive cells were detected using immunohistochemical analysis. The phenotype of the BrdU-positive cells was identified by fluorescent triple labeling by using antibodies specific for neuronal and astroglial markers together with anti-BrdU antibodies. The infarction was confirmed by applying cresyl violet staining. Compared with sham-operated control animals, there was a 4.6-fold (p < 0.05) increase in BrdU-positive cells in the ipsilateral DG at Day 7 postischemia. Twenty-one percent of the newly proliferated cells survived to Day 21 postischemia. At this time, the newly proliferated cells expressed the immature and mature neuron markers doublecortin and NeuN, respectively, but none expressed the astroglial marker glial fibrillary acidic protein. CONCLUSIONS: Focal ischemia induces neurogenesis in the DG of the mouse brain; this may be critical for postischemic brain repair.