Delayed spinal arachnoiditis with syringomyelia following aneurysmal subarachnoid haemorrhage: a case report with patient experience.

BACKGROUND AND IMPORTANCE: Syringomyelia, or the formation of fluid-filled cysts within the spinal cord, associated with delayed spinal arachnoiditis is an uncommon complication of aneurysmal subarachnoid haemorrhage. To date, about 18 cases have been reported in medical literature, with just two reported in patients under the age of 35 years. CLINICAL PRESENTATION: A 27-year-old female patient complained of sudden, severe headaches in the occipital region, nuchal rigidity, and drowsiness when she presented at our institution. A head computed tomography scan revealed intraventricular bleeding in the lateral and fourth ventricles with more extensive haemorrhaging in the frontal horns. A left posterior inferior cerebellar artery (PICA) aneurysm was confirmed via digital subtraction angiogram, and endovascular embolization was done. Two years later, the patient reported intense pain in the lower back along with symptoms suggestive of spinal cord compression. Spinal magnetic resonance imaging (MRI) showed spinal adhesions from C1 to L4, syringomyelia with some vasogenic oedema extending from T3 to T9 level, and a cyst in the lumbar region. Consequently, a right hemilaminectomy was performed along with microsurgical release of arachnoid adhesions and placement of a subdural drain. Radiological and symptomatic improvements were observed. Since then, the patient's clinical condition has remained stable during the past three years of follow-up visits. CONCLUSIONS: Literature on optimal treatment modalities and patient prognosis is scarce and debated. The time for symptom improvement depends on the level and extent of spinal cord involvement. Rehabilitation may be required for most patients, as complete symptomatic recovery may not be attainable.

Characteristics and Injury Patterns in Traumatic Brain Injury Related to E-Scooter Use in Riga, Latvia: Multicenter Case Series.

Background and Objectives: In recent years, electronic scooters (e-scooters) have gained popularity, whether for private use or as a publicly available transportation method. With the introduction of these vehicles, reports of e-scooter-related accidents have surged, sparking public debate and concern. The aim of this study was to analyze the epidemiological data, characteristics, and severity of traumatic brain injury (TBI) related to e-scooter accidents. Materials and Methods: This retrospective case series evaluated patients who were admitted to the three largest neurosurgery clinics in Riga, Latvia, from the time period of April to October in two separate years-2022 and 2023-after e-scooter-related accidents. The data were collected on patient demographics, the time of the accident, alcohol consumption, helmet use, the type of TBI, other related injuries, and the treatment and assessment at discharge. Results: A total of 28 patients were admitted with TBI related to e-scooter use, with a median age of 30 years (Q1-Q3, 20.25-37.25), four individuals under the age of 18, and the majority (64%) being male. In 23 cases, the injury mechanism was falling, in 5 cases, collision. None were wearing a helmet at the time of the injury. Alcohol intoxication was evident in over half of the patients (51.5%), with severe intoxication (>1.2 g/L) in 75% of cases among them. Neurological symptoms upon admission were noted in 50% of cases. All patients had intracranial trauma: 50% had brain contusions, 43% traumatic subdural hematoma, and almost 30% epidural hematoma. Craniofacial fractures were evident in 71% of cases, and there were fractures in other parts of body in three patients. Six patients required emergency neurosurgical intervention. Neurological complications were noted in two patients; one patient died. Conclusions: e-scooter-related accidents result in a significant number of brain and other associated injuries, with notable frequency linked to alcohol influence and a lack of helmet use. Prevention campaigns to raise the awareness of potential risks and the implementation of more strict regulations should be conducted.

Functional Disability and Brain MRI Volumetry Results among Multiple Sclerosis Patients during 5-Year Follow-Up.

Background and Objectives: We aimed to determine the link between brain volumetry results and functional disability calculated using the Expanded Disability Status Scale (EDSS) among multiple sclerosis (MS) patients in relation to the provided treatment (disease-modifying therapies (DMTs)) during a 5-year follow-up period. Materials and Methods: A retrospective cohort study was performed enrolling 66 consecutive patients with a confirmed diagnosis of MS, predominantly females (62% (n = 41)). Relapsing-remitting (RR) MS was noted in 92% (n = 61) of patients, with the rest being patients with secondary progressive (SP) MS. The mean age was 43.3 years (SD 8.3 years). All patients were evaluated clinically using the EDSS and "FreeSurfer© 7.2.0" radiologically during a 5-year follow-up. Results: A significant increase in patient functional disability was noted, calculated using the EDSS during a 5-year follow-up. The baseline EDSS ranged between 1 and 6 with a median of 1.5 (IQR 1.5-2.0), and after 5 years, the EDSS was between 1 and 7, with a median EDSS of 3.0 (IQR 2.4-3.6). Compared with RRMS patients, SPMS patients demonstrated a significant increase in EDSS score during a 5-year period, with a median EDSS of 2.5 in RRMS patients (IQR 2.0-3.3) and 7.0 (IQR 5.0-7.0) among SPMS patients. Significantly lower brain volumetry results in different brain areas were found, including cortical, total grey and white matter, p < 0.05. Statistically significant differences were observed between baseline volumetry results of the hippocampus and the middle anterior part of the corpus callosum and their volumetry results after 5 years, p < 0.001. In this study population, the thalamus did not demonstrate significant changes in volumetry results during follow-up, p > 0.05. The provided treatment (DMTs) did not demonstrate a significant impact on the brain MRI volumetry results during a 5-year follow-up, p > 0.05. Conclusions: Brain MRI volumetry seriously impacts the early detection of brain atrophic changes. In this study, significant relationship between brain magnetic resonance volumetry results and disability progression among MS patients with no important impact of the provided treatment was described. Brain MRI volumetry may aid in the identification of early disease progression among MS patients, as well as enrich the clinical evaluation of MS patients in clinical patient care.

The Impact of Revascularization in a Patient with Atypical Manifestations of Hypoperfusion.

Background and Objectives: Carotid revascularization is one of the most effective treatment options in patients with severe carotid artery stenosis causing hypoperfusion in basal ganglia. Atypical manifestations include hyperkinetic movements, noted as extremely rare. We report a case about a patient with 2-months-long complaints of Uncontrollable movements in his right side of the body subsided after carotid revascularization. Case presentation: A 71-year-old male was admitted to Pauls Stradins Clinical University Hospital with the main complaints of 2-months-long uncontrollable movements in his right hand and his right leg. When performing coordination tasks, slight inaccuracy was noted with the right-side extremities. Hyperkinetic movements-choreoathetosis in the right side of the patient's face, arm, and leg-were seen. Computed tomography angiography revealed subocclusion in the proximal segment of the left internal carotid artery and 30% stenosis in the proximal segment of the right internal carotid artery. The patient was consulted by a vascular surgeon. Eversion endarterectomy of the left internal carotid artery was performed. The early postoperative period occurred without complications. The patient was discharged from the hospital 2 days after the surgery in good overall health condition. Two months later, choreoathetotic movements in his right side of the body had markedly decreased. No focal neurologic deficits were noted. Conclusions: Revascularization may be effective by eliminating emboli and stenosis, leading to hypoperfusion in watershed territories. A case of a 71-year-old male patient with the main complaints of 2-months-long uncontrollable movements in his right side of the body subsiding after carotid revascularization was demonstrated. It is vital to recognize atypical manifestations of hypoperfusion, associated with stenosis in internal carotid arteries, to early make a diagnosis, to perform an appropriate treatment, and to reduce the risk of cerebral infarction in the future, resulting in a longer high-quality life for the patient.

Is Anticoagulation Necessary for Severely Disabled Cardioembolic Stroke Survivors?

Background and Objectives: Oral anticoagulants are the hallmark of cardioembolic stroke prevention, but they are frequently underused, especially in elderly patients and patients with paroxysmal atrial fibrillation. In our paper, we analyzed the long-term outcome of severely disabled cardioembolic stroke survivors depending on the prescribed antithrombotic secondary prevention medication. Materials and Methods: In our study, we retrospectively collected data for ischemic stroke (IS) patients treated in P. Stradins Clinical University hospital, Riga, Latvia, from 2014 until 2017. Patients' clinical data were collected using local stroke registry, including patients' demographic data, vascular risk factors, clinical findings, and laboratory results. Severely disabled stroke survivors were followed up by phone at 30/90/180/365 days after discharge. Patients' functional outcomes were assessed using the adapted version of The Rankin Focused Assessment-Ambulation. The collected data were compared in 4 groups according to prescribed secondary prevention medication. Results: A total of 682 (91.42%) patients were followed up and included in data analysis. The median age of patients was 80 (IQR = 75-85) years. Of these patients, 231 (31%) were males and 515 (69%) were females. One-year probability of survival of patients not taking any preventive medication was 53% (IQR = 29-76), while in patients taking antiplatelet agents it was 57% (IQR = 37-78), 78% (IQR = 68-88) of patients on Vitamin K antagonists (VKA) and 81% (IQR = 72-90) in patients on direct oral anticoagulants (DOACs). One year after discharge 73 (31%) had mRS 0-2, 50 (20.9%), 29 (12.1%) were still severely disabled, and 87 (36.4%) had died. Conclusions: Anticoagulant use in secondary prevention predicts better functional outcome and higher survival rate in patients with severe cardioembolic stroke due to non-valvular atrial fibrillation (NVAF), therefore severe neurological deficit must not be a reason of restriction of anticoagulation.

Changes in Cognition, Depression and Quality of Life after Carotid Stenosis Treatment.

BACKGROUND: Although several studies have evaluated the change of cognitive performance after severe carotid artery stenosis, the results still remain elusive. The objective of this study was to assess changes in cognitive function, depressive symptoms and Health Related Quality of Life (HRQoL) after carotid stenosis revascularisation and Best Medical Treatment (BMT). METHODS: Study involved 213 patients with ≥70% carotid stenosis who underwent assessment of cognitive function using Montreal Cognitive Assessment scale (MoCA), depressive symptoms - using Patient Health Questionnaire-9 (PHQ-9) and HRQoL - using Medical Outcome Survey Short Form version 2 (SF-36v2). The assessment was performed before and at 6 and 12 months followup periods in patients who had Carotid Endarterectomy (CEA), Carotid Artery Stenting (CAS) or received BMT only. RESULTS: Improvement in the total MoCA scores was observed after 6 and 12 months (p<0.001, Kendall's W=0.28) in the CEA group. In the CAS group - after 12 months (p=0.01, Kendall's W=0.261) whereas in the BMT group - no significant changes (p=0.295, Kendall's W=0.081) were observed. Reduction of depressive symptoms was not found in any of the study groups. Comparing mean SF-36v2 scores in the CEA group, there was no significant difference in any of 10 subscales. Likewise in the CAS group - no significant difference in 9 of 10 subscales (p=0.028, η2=0.343) was observed. Three subscales worsened in the BMT group during the 1-year follow-up period. CONCLUSION: Patients with severe carotid stenosis who underwent revascularisation enhanced their cognitive performance without exerting significant change of depressive symptoms. Preoperative HRQoL may be maintained for at least one year in the CEA group.

Endovascular thrombectomy in anterior circulation stroke and clinical value of bridging with intravenous thrombolysis.

BACKGROUND: Bridging treatment with intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in acute ischemic stroke is applied under the assumption of benefits for patients with large vessel occlusion (LVO). However, the benefit of this additional step has not yet been proven. PURPOSE: To compare procedural parameters (procedural time, number of attempts), complications, and clinical outcome in patients receiving EVT vs. patients with bridging treatment. MATERIAL AND METHODS: In this prospective study all patients had acute anterior cerebral circulation occlusion and were treated with EVT. All patients were selected for treatment based on clinical criteria, multimodal computed tomography (CT) imaging. Eighty-four patients were treated with bridging IVT followed by EVT; 62 patients were treated with EVT only. RESULTS: Bridging therapy did not influence endovascular procedure time ( P = 0.71) or number of attempts needed ( P = 0.63). Bleeding from any site was more common in the bridging group (27, 32%) vs. the EVT group (12, 19%) ( P = 0.09). Functional independence modified Rankin Scale after 90 days was slightly higher in the bridging group (44%) vs. the EVT group (42%) ( P = 0.14). Mortality did not differ significantly at 90 days: 17% in the bridging group vs. 21% in EVT alone ( P = 0.57). Both treatment methods showed high recanalization rates: 94% in the bridging group and 89% for EVT alone. CONCLUSION: Bridging treatment in LVO did not show benefits or elevated risks of complications in comparison to EVT only. The bridging group did not show significantly better neurological outcome or significant impact on procedural parameters vs. EVT alone.

The adaption and evaluation of a Latvian version of the National Institutes of Health Stroke Scale.

Objectives To determine the validity and reliability of a Latvian version of the National Institutes of Health Stroke Scale (LV-NIHSS) for evaluating Latvian stroke patients. Methods The adaption of the LV-NIHSS followed standard methods used for the adaption and validation of clinical assessment tools. The scale validity was tested by comparison with the Glasgow Coma Scale (GCS) and the modified Rankin scale (mRs). The reliability of the LV-NIHSS was evaluated by intra-rater and inter-rater agreement using intra-class correlation coefficient (ICC) analysis. Results A total of 296 stroke patients and 101 control subjects were evaluated. The mean age of the overall study population was 73.6 years (range, 37 - 94 years; 227 [57.2%] were female). The mean LV-NIHSS score of the patients with stroke was 8.4 ± 6.2. In terms of construct validity of the LV-NIHSS, it correlated with the GCS ( r = -0.571) and mRs ( r = 0.755). In terms of the reliability of the LV-NIHSS, the inter-rater agreement had an ICC of 0.99 and the intra-rater agreement had an ICC of 0.99. Conclusion The adaption of LV-NIHSS was successful and the evaluation showed that the scale was valid and reliable for evaluating Latvian stroke patients.

Evaluation of axonal optic nerve damage using visual evoked potentials and optical coherence tomography in patients with multiple sclerosis.

BACKGROUND AND OBJECTIVE: Axonal tissue impairment plays a substantial role in the development of disability in multiple sclerosis. The aim of our study was to analyze the clinical utility of visual evoked potentials (VEP) and optical coherence tomography (OCT) in the diagnosis of optic nerve axonal damage and to determine the correlation between the retinal nerve fiber layer at the temporal quadrant (RNFLT) thickness and the VEP amplitude in multiple sclerosis patients with and without a history of acute optic neuritis (ON). MATERIAL AND METHODS: This cross-sectional study included 69 relapsing-remitting patients with multiple sclerosis from Pauls Stradins Clinical University Hospital, who were divided into 2 groups: with and without a history of ON. The RNFLT thickness and the VEP amplitude were measured. RESULTS. A total of 25 clinically affected eyes were studied. VEP showed a higher sensitivity (64%) than OCT (50%) in supporting a clinical diagnosis of ON. A significant correlation was found between the RNFLT thickness in the temporal segment and the average VEP amplitude both in the eyes of MS patients with (rs=0.42, P=0.01) and without a history of ON (rs=0.44, P<0.001). CONCLUSIONS: The evidence from this study suggests that diagnostics of optic nerve axonal damage is feasible by means of using the average VEP amplitude instead of OCT alone. However, the combination of VEP and OCT increases the chance to confirm the existence of ON. A significant correlation was found between structural and functional vision parameters for both patients with and without a history of ON.

Preliminary results of randomized controlled study on decompressive craniectomy in treatment of malignant middle cerebral artery stroke.

BACKGROUND AND OBJECTIVE: Studies on decompressive craniectomy (DCE) after a malignant middle cerebral artery (MCA) stroke in selected population show an increased probability of survival without increasing the number of very severely disabled. Cerebral infarct volume (CIV) as a triage criterion for performing surgery has not been discussed in literature. The aim of this study was to investigate the value of CIV and initial National Institutes of Health Stroke Scale (NIHHS) and Glasgow Coma Scale (GCS) scores as possible triage criteria in the surgical treatment of patients with "malignant" MCA stroke. MATERIAL AND METHODS: According to the study protocol, 28 patients with a malignant MCA stroke were included and analyzed prospectively. The patients were randomly divided either into the DCE plus best medical treatment (BMT) group or BMT alone group. CIV and NIHHS and GCS scores were measured at time of enrollment in every case. Clinical outcome was evaluated 1 year after the treatment. RESULTS: Six patients survived: 5 in the DCE group (none of them was older than 60 years) and 1 in the BMT group (P=0.03/0.06). Among survivors, none had a cerebral infarct volume of more than 390 cm(3) (P=0.05). All survivors in the DCE group had favorable outcomes. There was no significant difference in the NIHSS and GCS scores between the groups and survivors/nonsurvivors (P>0.05). CONCLUSIONS: Decompressive surgery in the selected patients is likely to increase the probability of survival with a favorable outcome without increasing the number of severely disabled survivors. Patients with CIV of more than 390 cm(3) may be bad candidates for DCE, and the prognosis is likely to be bad regardless the treatment strategy. The initial NIHHS and GCS scores did not prove any prognostic value in outcome.

Human herpesvirus 6 and 7 reactivation and disease activity in multiple sclerosis.

UNLABELLED: Recent studies have focused on the associations between human herpesvirus 6 (HHV-6) and human herpesvirus 7 (HHV-7), and multiple sclerosis (MS). The aim of this study was to investigate the associations between HHV-6 and HHV-7 reactivation and MS disease activity, and interleukin 12 (IL-12) and tumor necrosis factor α (TNF-α) production. MATERIAL AND METHODS: The frequency of plasma viremia by nested polymerase chain reaction and transcription of viral mRNA in peripheral blood mononuclear cells by reverse transcriptase-polymerase chain reaction (RT-PCR) of 14 relapsing/remitting (RR) and 14 secondary progressive (SP) MS patients were studied in comparison with clinical manifestation of the disease. Serum concentrations of cytokines IL-12 and TNF-α were analyzed by enzyme-linked immunosorbent assay. RESULTS: Plasma samples from 25 of the 28 MS patients with estimated latent/persistent HHV-6 and/or HHV-7 infection were examined during relapse and remission/relative remission. HHV-6 reactivation was found in 4 of the 7 RRMS and 4 of the 7 SPMS patients, and HHV-7 reactivation was identified in 3 of the 7 RRMS and 1 of the 7 SPMS patients (all in relapse). In 2 of the 3 RRMS patients without viremia in relapse, HHV-6 mRNA transcription was detected. In RRMS and SPMS patients with active HHV-6 and HHV-7 infection in relapse, the serum concentrations of IL-12 and TNF-α were significantly higher than in those with latent virus infection. CONCLUSIONS: HHV-6 and HHV-7 reactivation could be implicated in the exacerbation of MS via activation of Th1 lymphocyte subsets.

The relationship between seropositivity against Chlamydia pneumoniae and stroke and its subtypes in a Latvian population.

BACKGROUND AND OBJECTIVE: Serological evidence of infection with Chlamydia pneumoniae has been associated with cardiovascular diseases, but the relationship with stroke and its risk factors remains not completely understood. The aim of this study was to determine whether serological evidence of infection with Chlamydia pneumoniae was associated with the risk of ischemic stroke and any of investigated stroke subtypes. MATERIAL AND METHODS: Confirmed stroke cases (n=102) were compared with gender- and age-matched control patients (n=48). The patients with stroke were divided into 3 groups according to the TOAST criteria: atherothrombotic (n=36), cardioembolic (n=47), and of undetermined etiology (n=19). Plasma levels of IgG antibodies to Chlamydia pneumoniae were measured by enzyme-linked immunosorbent assay. RESULTS: There was a significant association between seropositivity to Chlamydia pneumoniae and stroke. Anti-Chlamydia pneumoniae IgG antibodies were detected in 64 case patients (62.7%) and 17 control patients (35.4%) (χ(2)=9.8; df=1; P=0.002). IgG seropositivity to Chlamydia pneumoniae was linked to all the analyzed etiological subtypes of stroke. CONCLUSION: This study showed that IgG seropositivity to Chlamydia pneumoniae was associated with stroke and all the analyzed etiological subtypes of stroke.

Correlation between HHV-6 reactivation and multiple sclerosis disease activity.

This study examined the association between HHV-6 infection and multiple sclerosis (MS) and the relationship between HHV-6 reactivation and disease activity. The frequency of HHV-6 genomic sequences in peripheral blood mononuclear cells (PBMCs), the incidence of plasma viremia (nPCR), the transcription of viral mRNA in PBMCs (RT-PCR), the presence of antiviral IgM and IgG class antibodies in the plasma (IFA) of 16 relapsing/remitting and secondary progressive MS patients were studied in comparison with clinical manifestations of the disease, magnetic resonance imaging (MRI) of brain, and serum interleukin (IL)-12 concentrations (ELISA). The prevalence of HHV-6 infection was significantly higher in patients with MS (16/26) than in patients with other neurological diseases (6/21) and in blood donors (43/150). HHV-6 reactivation was found during periods of disease activity with Gadolinium-enhancing lesions on MRI in both relapsing/remitting and secondary progressive MS (10/13; 76.9%). In patients with active MS disease, serum concentrations of IL-12 were significantly higher in those patients with active HHV-6 infection than in patients with latent infection. The data confirm an association between HHV-6 infection and MS and show a correlation between HHV-6 reactivation and disease activity in relapsing/remitting and secondary progressive MS. The risk of an exacerbation of MS was significantly higher (P < 0.005) in patients with active HHV-6 infection than in patients with latent infection. A clear correlation between HHV-6 reactivation and serum IL-12 concentrations during disease activity has been demonstrated. The results suggest that HHV-6 reactivation is implicated in exacerbation of MS, possibly through modulation of IL-12 synthesis.