Ischemic Stroke due to Intracranial Embolization of a Pelvic Phlebolith in a Pregnant Patient Successfully Treated by Surgical Embolectomy following Attempted Endovascular Thrombectomy.

An unusual case of ischemic stroke due to calcified cerebral embolus occurring in a pregnant patient during the peripartum period is reported. The source of the embolus was suspected to be a pelvic phlebolith in origin which paradoxically embolized via a patent foramen ovale to the supraclinoid right internal carotid artery. To our knowledge, this is the first reported case of calcified cerebral embolus attributed to paradoxical embolism of a pelvic phlebolith, and we theorize that introduction of the phlebolith into the venous system may have occurred as a consequence of vascular remodeling due to pregnancy-related hemodynamic changes. Clinicians should be aware of this potential source of calcified cerebral emboli in patients with a patent foramen ovale during pregnancy. Our patient ultimately achieved an excellent outcome with surgical endarterectomy and embolectomy following an unsuccessful attempt at mechanical thrombectomy.

Diffusion in the corpus callosum predicts persistence of clinical symptoms after mild traumatic brain injury, a multi-scanner study.

Background: Mild traumatic brain injuries (mTBIs) comprise 80% of all TBI, but conventional MRI techniques are often insensitive to the subtle changes and injuries produced in a concussion. Diffusion tensor imaging (DTI) is one of the most sensitive MRI techniques for mTBI studies with outcome and symptom associations described. The corpus callosum (CC) is one of the most studied fiber tracts in TBI and mTBI, but the comprehensive post-mTBI symptom relationship has not fully been explored. Methods: This is a retrospective observational study of how quantitative DTI data of the CC and its sub-regions may relate to clinical presentation of symptoms and timing of resolution of symptoms in patients diagnosed with uncomplicated mTBI. DTI and clinical data were obtained retrospectively from 446 (mean age 42 years, range 13-82) civilian patients. From patient medical charts, presentation of the following common post-concussive symptoms was noted: headache, balance issues, cognitive deficits, fatigue, anxiety, depression, and emotional lability. Also recorded was the time between injury and a visit to the physician when improvement or resolution of a particular symptom was reported. FA values from the total CC and 3 subregions of the CC (genu or anterior, mid body, and splenium or posterior) were obtained from hand tracing on the Olea Sphere v3.0 SP12 free-standing workstation. DTI data was obtained from 8 different 3T MRI scanners and harmonized via ComBat harmonization. The statistical models used to explore the association between regional Fractional Anisotropy (FA) values and symptom presentation and time to symptom resolution were logistic regression and interval-censored semi-parametric Cox proportional hazard models, respectively. Subgroups related to age and timing of first scan were also analyzed. Results: Patients with the highest FA in the total CC (p = 0.01), anterior CC (p < 0.01), and mid-body CC (p = 0.03), but not the posterior CC (p = 0.91) recovered faster from post-concussive cognitive deficits. Patients with the highest FA in the posterior CC recovered faster from depression (p = 0.04) and emotional lability (p = 0.01). There was no evidence that FA in the CC or any of its sub-regions was associated with symptom presentation or with time to resolution of headache, balance issues, fatigue, or anxiety. Patients with mTBI under 40 had higher FA in the CC and the anterior and mid-body subregions (but not the posterior subregion: p = 1.00) compared to patients 40 or over (p ≤ 0.01). There was no evidence for differences in symptom presentation based on loss of consciousness (LOC) or sex (p ≥ 0.18). Conclusion: This study suggests that FA of the CC has diagnostic and prognostic value for clinical assessment of mTBI in a large diverse civilian population, particularly in patients with cognitive symptoms.

Intervertebral kinematics during neck motion 6.5 years after fusion and artificial disc replacement.

BACKGROUND: Arthroplasty with artificial disc replacement for surgical treatment of cervical spine degeneration was introduced with the notion that motion-preserving approaches would prevent development of adjacent segment disease. Though clinical outcomes favor arthroplasty over the commonly used anterior cervical discectomy with fusion approach, clinical studies confirming the biomechanical basis of these results are lacking. The aim of this study was to compare intervertebral kinematics between arthroplasty and fusion patients 6.5 years post-surgery during physiological motion of the neck. METHODS: Using a biplane dynamic X-ray system, computed tomography imaging and model based tracking algorithms, three dimensional intervertebral kinematics were measured during neck axial rotation and extension in 14 patients treated for cervical radiculopathy with fusion (n = 8) or arthroplasty (n = 6). The measurements were performed at 2-year (baseline) and 6.5 year post-surgical time points, with the main interest being in the interaction between surgery types and time points. 3 translations and 3 rotations were investigated for the index (C5C6), and upper- (C4C5) and lower adjacent levels (C6C7). FINDINGS: Surgery-time interaction was significant for axial rotation (P < 0.04) and flexion-extension rotation (P < 0.005) in C4C5 during neck axial rotation, left-right translation (P < 0.04) in C5C6 and anterior-posterior translation in C6C7 (P < 0.04) during neck extension. In contrast with the expectations, axial rotation and flexion-extension decreased in C4C5 during neck rotation and anterior-posterior translation decreased in C6C7 during neck extension for fusion. INTERPRETATION: The findings do not support the notion that adjacent segment motion increases after fusion.

Hematuria in pregnancy due to renal arteriovenous malformation: A case report.

A 31-year-old pregnant woman at 22 weeks and 2 days of gestation presented to the emergency room with complaints of painless hematuria and passage of clots. Initial computed tomography angiography (CTA) of the abdomen and pelvis performed after ultrasound revealed evidence of blood products in the bladder. However, the CTA did not reveal any source of bleeding. Given hemodynamic instability and persistent pain, the patient was taken to the operating room for a cystoscopy, which revealed bleeding from the left renal unit, giving rise to suspicion of a renal arteriovenous malformation (AVM). The patient then underwent left renal digital subtraction angiography (DSA), which produced no evidence of active bleeding. Due to high clinical suspicion and ongoing symptomatic hematuria, she underwent DSA a second time, which did demonstrate renal AVM bleeding, and embolization was performed. This case highlights the importance of cystoscopy in diagnosing a renal AVM in a pregnant patient despite the risks of general anesthesia during pregnancy.

Dynamic foraminal dimensions during neck motion 6.5 years after fusion and artificial disc replacement.

OBJECTIVE: To compare changes in foraminal motion at two time points post-surgery between artificial disc replacement (ADR) and anterior cervical discectomy and fusion (ACDF). METHODS: Eight ACDF and 6 ADR patients (all single-level C5-6) were tested at 2 years (T1) and 6.5 years (T2) post-surgery. The minimum foraminal height (FH.Min) and width (FW.Min) achieved during neck axial rotation and extension, and the range of these dimensions during motion (FH.Rn and FW.Rn, respectively) were measured using a biplane dynamic x-ray system, CT imaging and model-based tracking while patients performed neck axial rotation and extension tasks. Two-way mixed ANOVA was employed for analysis. RESULTS: In neck extension, significant interactions were found between year post-surgery and type of surgery for FW.Rn at C5-6 (p<0.006) and C6-7 (p<0.005), and for FH.Rn at C6-7 (p<0.01). Post-hoc analysis indicated decreases over time in FW.Rn for ACDF (p<0.01) and increases in FH.Rn for ADR (p<0.03) at the C6-7 adjacent level. At index level, FW.Rn was comparable between ACDF and ADR at T1, but was smaller for ACDF than for ADR at T2 (p<0.002). In axial rotation, differences were found between T1 and T2 but did not depend on type of surgery (p>0.7). CONCLUSIONS: Changes were observed in the range of foraminal geometry at adjacent levels from 2 years to 6.5 years post-surgery that were different between ACDF and ADR for neck extension. These changes are contrary to the notion that motion at adjacent levels continue to increase following ACDF as compared to ADR over the long term.

Delayed Cerebral Ischemia of the Corpus Callosum: A Case Report.

Ischemic infarction of the corpus callosum is a rare condition due to its rich vascular supply and therefore has been infrequently reported. Here, we present a case of a patient who developed a delayed infarct of the corpus callosum in the body. The condition was characterized by bilateral lower extremity weakness and visual disturbances following intraventricular hemorrhage managed with ventriculostomy. Understanding the anatomy and function of the corpus callosum is crucial to understanding the etiology of infarctions as well as their clinical significance. It is also essential to distinguish between relatively common post-shunting changes and true infarction and to recognize the limited consequences of corpus callosum infarction. Increased awareness of this rare infarct would help to prevent unnecessary interventions and increase the ability of the physician to provide optimal care for the patient.

Hypoxic Preconditioning Protects SH-SY5Y Cell against Oxidative Stress through Activation of Autophagy.

Oxidative stress plays a role in many neurological diseases. Hypoxic preconditioning (HPC) has been proposed as an intervention that protects neurons from damage by altering their response to oxidative stress. The aim of this study was to investigate the mechanisms by which HPC results in neuroprotection in cultured SH-SY5Y cells subjected to oxidative stress to provide a guide for future investigation and targeted interventions. SH-SY5Y cells were subjected to HPC protocols or control conditions. Oxidative stress was induced by H2O2. Cell viability was determined via adenosine triphosphate assay. Rapamycin and 3-methyxanthine (3-MA) were used to induce and inhibit autophagy, respectively. Monodansylcadaverine staining was used to observe the formation of autophagosomes. Levels of Microtubule-associated protein light chain 3 B (LC3B), Beclin 1, and p53 were measured by Western blot. Reactive oxygen species (ROS) were also determined. Cell viability in the HPC group following 24-h exposure to 600 µM H2O2 was 65.04 ± 12.91% versus 33.14 ± 5.55% in the control group. LC3B, Beclin 1, and autophagosomes were increased in the HPC group compared with controls. Rapamycin mimicked the protection and 3-MA decreased the protection. There was a moderate increase in ROS after HPC, but rapamycin can abolish the increase and 3-MA can enhance the increase. p53 accumulated in a manner consistent with cell death, and HPC-treated cells showed reduced accumulation of p53 as compared with controls. Treatment with rapamycin decreased p53 accumulation, and 3-MA inhibited the decrease in p53 induced by HPC. HPC protects against oxidative stress in SH-SY5Y cells. Mechanisms of protection may involve the activation of autophagy induced by ROS generated from HPC and the following decline in p53 level caused by activated autophagy in oxidative stress state. This is in line with recent findings in nonneuronal cell populations and may represent an important advance in understanding how HPC protects neurons from oxidative stress.