TCCD Fusion Imaging to Estimate Intracranial Pressure and Tissue Displacement with Large Hemispheric Infarction.

BACKGROUND: Despite breakthroughs in stroke treatment, some patients still experience large infarctions of the cerebral hemispheres resulting in mass effect and tissue displacement. The evolution of mass effect is currently monitored using serial computed tomography (CT) imaging. However, there are patients who are ineligible for transport, and there are limited options for bedside monitoring of unilateral tissue shift. METHODS: We used fusion imaging for overlaying transcranial color duplex with CT angiography. This method allows overlay of live ultrasound on top of CT or magnetic resonance imaging scans. Patients with large hemispheric infarctions were eligible to participate. Position data from the source files were used and matched with live imaging and correlation to magnetic probes on the patient's forehead and ultrasound probe. Shift of cerebral parenchyma, displacement of the anterior cerebral arteries, basilary artery and third ventricle were analyzed, as well as pressure on the midbrain, and the displacement of the basilar artery on the head were analyzed. Patients received multiple examinations in addition to standard care of treatment with CT imaging. RESULTS: The sensitivity for diagnosing a shift of 3 mm with fusion imaging was 100%, with a specificity of 95%. No side effects or interactions with critical care equipment were recorded. CONCLUSIONS: Fusion imaging is an easy method to access and acquire measurements for critical care patients and follow-up of tissue and vascular displacement after stroke. Fusion imaging may be a decisive support for indicating hemicraniectomy.

Age-related changes in oral sensitivity, taste and smell.

Oropharyngeal sensitivity plays a vital role in the initiation of the swallowing reflex and is thought to decline as part of the aging-process. Taste and smell functions appear to decline with age as well. The aim of our study was to generate data of oral sensitivity in healthy participants for future studies and to analyse age-related changes and their interdependence by measuring oral sensitivity, taste, and smell function. The experiment involved 30 participants younger than and 30 participants older than 60. Sensitivity threshold as a surrogate of oral sensitivity was measured at the anterior faucial pillar by electrical stimulation using commercially available pudendal electrode mounted on a gloved finger. Smell and taste were evaluated using commercially available test kits. Mean sensitivity was lower in young participants compared to older participants (1.9 ± 0.59 mA vs. 2.42 ± 1.03 mA; p = 0.021). Young participants also performed better in smell (Score 11.13 ± 0.86 vs 9.3 ± 1.93; p < 0.001) and taste examinations (Score 11.83 ± 1.86 vs 8.53 ± 3.18; p < 0.001). ANCOVA revealed a statistical association between sensitivity and smell (p = 0.08) that was moderated by age (p = 0.044). Electrical threshold testing at the anterior faucial pillar is a simple, safe, and accurate diagnostic measure of oral sensitivity. We detected a decline of oral sensitivity, taste, and smell in older adults.Trial registration: Clinicaltrials.gov, NCT03240965. Registered 7th August 2017- https://clinicaltrials.gov/ct2/show/NCT03240965 .

Neuromuscular sonography detects changes in muscle echotexture and nerve diameter in ICU patients within 24 h.

PURPOSE: During an ICU stay, changes in muscles and nerves occur that is accessible via neuromuscular sonography. METHODS: 17 patients recruited from the neurological and neurosurgical ICU (six women; 66 ± 3 years) and 7 healthy controls (three women, 75 ± 3 years) were included. Muscle sonography (rectus abdominis, biceps, rectus femoris and tibialis anterior muscles) using gray-scale values (GSVs), and nerve ultrasound (peroneal, tibial and sural nerves) analyzing the cross-sectional area (CSA) were performed on days 1 (t1), 3 (t2), 5 (t3), 8 (t4), and 16 (t5) after admission. RESULTS: Time course analysis revealed that GSVs were significantly higher within the patient group for all of the investigated muscles (rectus abdominis: F = 7.536; p = 0.011; biceps: F = 14.761; p = 0.001; rectus femoris: F = 9.455; p = 0.005; tibialis anterior: F = 7.282; p = 0.012). The higher GSVs were already visible at t1 or, at the latest, at t2 (tibialis anterior muscles). CSA was enlarged in all of the investigated nerves in the patient group (peroneal nerve: F = 7.129; p = 0.014; tibial nerve: F = 28.976, p < 0.001; sural nerve: F = 13.051; p = 0.001). The changes were visible very early (tibial nerve: t1; peroneal nerve: t2). The CSA of the motor nerves showed an association with the ventilation time and days within the ICU (t1 through t4; p < 0.05). DISCUSSION: We detected very early changes in the muscles and nerves of ICU-patients. Nerve CSA might be a useful parameter to identify patients who are at risk for difficult weaning. Therefore our observations might be severity signs of neuromuscular suffering for the most severe patients.

Case Report: Take a Second Look: Covid-19 Vaccination-Related Cerebral Venous Thrombosis and Thrombotic Thrombocytopenia Syndrome.

We present two cases of ChAdOx1 nCov-19 (AstraZeneca)-associated thrombotic thrombocytopenia syndrome (TTS) and cerebral venous sinus thrombosis (CVST). At the time of emergency room presentation due to persistent headache, blood serum levels revealed reduced platelet counts. Yet, 1 or 4 days after the onset of the symptom, the first MR-angiography provided no evidence of CVST. Follow-up imaging, performed upon headache refractory to nonsteroidal pain medication verified CVST 2-10 days after initial negative MRI. Both the patients received combined treatment with intravenous immunoglobulins and parenteral anticoagulation leading to an increase of platelet concentration in both the individuals and resolution of the occluded cerebral sinus in one patient.

Superficial siderosis as a rare cause of visual and auditory pseudohallucinations: a case report.

BACKGROUND: Superficial siderosis is a rare disease involving hemosiderin deposits on the surface of brain or spinal cord that are thought to cause clinical symptoms, which usually consist of cranial nerve dysfunction, cerebellar ataxia, or myelopathy. Pseudohallucinations have been described as the patient being aware of the nonreality of hallucination-like phenomena. Data on pseudohallucinations of cerebral somatic origin are sparse. We present a case of auditory and visual pseudohallucinations due to superficial siderosis. Siderosis was diagnosed using cerebrospinal fluid analysis and magnetic resonance imaging as part of the clinical routine for newly emerged psychiatric symptoms. CASE PRESENTATION: An 84-year-old white/european female presented to our hospital with no prior history of psychiatric or neurological disease and no history of trauma. She reported seeing things and hearing voices singing to her for some days. She was aware these phenomena were not real (pseudohallucinations). On examination, no relevant abnormalities were detected. Cerebrospinal fluid analysis showed elevated ferritin. Magnetic resonance imaging with susceptibility-weighted sequences revealed diffuse superficial siderosis in several parts of the brain, among other occipital and temporal gyri. The pseudohallucinations resolved with a risperidone regime. The patient was treated with rivaroxaban because of atrial fibrillation. Potentially elevating the risk of further hemorrhage, this therapy was discontinued, and an atrial appendage occlusion device was implanted. CONCLUSION: We report the first case of pseudohallucinations in superficial siderosis. The risk of missing this diagnosis can be reduced by applying a standardized diagnostic pathway for patients presenting with the first episode of psychiatric symptoms. Somatic and potentially treatable causes should not be missed because they might lead to unnecessary treatments, stigmatization, and legal restrictions of self-determination, especially for elderly people.

Facilitation of oral sensitivity by electrical stimulation of the faucial pillars.

Dysphagia is common in neurological disease. However, our understanding of swallowing and its central nervous control is limited. Sensory information plays a vital role in the initiation of the swallowing reflex and is often reduced in stroke patients. We hypothesized that the sensitivity threshold of the anterior faucial pillar could be facilitated by either electrical stimulation (ES) or taste and smell information. The sensitivity threshold was measured by ES in the anterior faucial pillar region. The measurement was repeated 5 min after baseline. Thirty minutes after baseline, the participants underwent a test for taste and smell. Immediately after the test, the ES was repeated. Thirty healthy volunteers with a mean age of 27 ± 5.1 participated in the trial. Mean sensitivity threshold at baseline was 1.9 ± 0.59 mA. The values 5 min after baseline (1.74 ± 0.56 mA, p = 0.027) and 30 min after baseline (1.67 ± 0.58 mA, p = 0.011) were significantly lower compared to the baseline, but there was no difference between the latter (p = 0.321). After 5 min, a potentially facilitating effect was found on oral sensitivity by ES of the faucial pillar area. Thirty minutes later, this effect was still present.Trial registration Clinicaltrials.gov, NCT03240965. Registered 7th August 2017- https://clinicaltrials.gov/ct2/show/NCT03240965 .

Case Report: A Well-Hidden Cause for Myelopathy.

Introduction: Sarcoidosis is a rare, systemic inflammatory disease and can involve multiple organs, especially the lungs and lymph nodes. The nervous system is affected in <10 percent of patients, which is called neurosarcoidosis. Neurosarcoidosis can cause a multitude of symptoms and can mimic various diseases. A rare manifestation is bone marrow involvement. We describe a case of spinal cord syndrome due to myelopathy that was caused by sarcoidosis of the bone marrow. Case Presentation: A male patient presented to our hospital with incomplete spinal cord syndrome. He suffered from numbness of the legs which had progressed to severe paraparesis. Magnetic resonance imaging revealed thoracic myelopathy without contrast enhancement. Thorough diagnostics found no explanation for the myelopathy, and the patient was treated symptomatically with high-dose steroids. When the patient developed non-resolving leukopenia, a bone marrow biopsy was performed. The bone marrow showed changes due to sarcoidosis. Further testing revealed myocardial involvement of the sarcoidosis. The patient was started on oral prednisolone and methotrexate. Over the course of time, his symptoms improved, but he still suffers from spastic leg paresis and needs aids to walk farther than 1 kilometre. Conclusion: In patients presenting with neurological deficits of unknown cause, neurosarcoidosis is a potential explanation. If it manifests primarily in the bone marrow, the diagnosis can be easily overlooked. Abnormalities in a full blood count should make the treating physician consider this diagnosis, and a bone marrow biopsy should be performed.

Flexible endoscopic evaluation of swallowing (FEES) to determine neurological intensive care patients' oral diet.

PURPOSE: Dysphagia is common in critically ill neurological patients and is associated with a high mortality and morbidity. Data on the usefulness of flexible endoscopic examination of swallowing (FEES) in neurological intensive care unit (ICU) patients are lacking, raising the need for evaluation. METHOD: FEES was performed in neurological intensive care patients suspected of dysphagia. We correlated findings with baseline data, disability status, pneumonia and duration of hospitalisation, as well as a need for mechanical ventilation or tracheotomy. RESULT: This analysis consisted of 125 patients with suspected dysphagia. Most of the patients (81; 64,8%) suffered from acute stroke. Dysphagia was diagnosed using FEES in 90 patients (72%). FEES results led to dietary modifications in 80 patients (64%). The outcome at discharge was worse in dysphagic stroke patients diagnosed by FEES as compared to non-dysphagic stroke patients (p = 0.009). Patients without oral diet had higher need for intubation (p = 0.007), tracheotomy (p = 0.032) and higher mortality (p < 0.001) in comparison to patients with at least small amounts of oral intake. CONCLUSION: As the clinical assessment of the patients often classified the dysphagia incorrectly, the broad use of FEES in ICU patients might help to adequately adjust patients' oral diet. This knowledge might contribute to lower mortality and morbidity.

Adjustment of oral diet based on flexible endoscopic evaluation of swallowing (FEES) in acute stroke patients: a cross-sectional hospital-based registry study.

BACKGROUND: Diagnosing dysphagia in acute stroke patients is crucial, as this comorbidity determines morbidity and mortality; we therefore investigated the impact of flexible nasolaryngeal endoscopy (FEES) in acute stroke patients. METHODS: The FEES investigation as performed in acute stroke patients treated at a large university hospital, allocated as a standard procedure for all patients suspected of dysphagia. We correlated our findings with baseline data, disability status, pneumonia, duration of hospitalisation, necessity for mechanical ventilation and treatment on the intensive care unit. The study was designed as a cross-sectional hospital-based registry. RESULTS: We investigated 152 patients. The median age was 73; 94 were male. Ischemic stroke was diagnosed in 125 patients (82.2%); 27 (17.8%) suffered intracerebral haemorrhage. Oropharyngeal dysphagia was diagnosed in 72.4% of the patients, and was associated with higher stroke severity on admission (median NIHSS 11 [IQR 6-17] vs. 7 [4-12], p = .013; median mRS 5 [IQR 4-5] vs. 4 [IQR 3-5], p = .012). Short-term mortality was higher among patients diagnosed with dysphagia (7.2% vs. 0%, p = .107). FEES examinations revealed that only 30.9% of the patients had an oral diet appropriate for their swallowing abilities. A change of oral diet was associated with a better outcome at discharge (mRS; p = .006), less need of mechanical ventilation (p = .028), shorter period of hospitalisation (p = .044), and lower rates of pneumonia (p = .007) and mortality (p = .011). CONCLUSION: Due to the inability of clinical assessments to detect silent aspiration, FEES might be better suited to identify stroke patients at risk and may contribute to a better functional outcome and lower rates of pneumonia and mortality. Our findings also point to a low awareness of dysphagia, even in a specialised stroke centre. FEES in acute stroke patients helps to adjust the oral diet for the vast majority of stroke patients (69.1%) based on their swallowing abilities, potentially avoiding severe complications.

What is the value of fibre-endoscopic evaluation of swallowing (FEES) in neurological patients? A cross-sectional hospital-based registry study.

OBJECTIVES: Fibre-endoscopic evaluation of swallowing (FEES) to detect dysphagia is gaining more and more importance as a diagnostic tool. Therefore, we have investigated the impact of FEES in neurological patients in a clinical setting. DESIGN: Cross-sectional hospital-based registry. SETTING: Primary acute care in a neurological department of a German university hospital. PARTICIPANTS: 241patients with various neurological diseases who underwent FEES procedure. PRIMARY AND SECONDARY OUTCOME MEASURES: Dysphagia and related comorbidities. RESULTS: 267 FEES were performed in 241 patients with various neurological diagnoses. Dysphagia was diagnosed in 68.9% of the patients. In only 33.1% of the patients, appropriate oral diet was chosen prior to FEES. A relevant dysphagia occurred more often in patients with structural brain lesions (83.1% vs 65.3%, P=0.001), patients with dysphagia had a longer hospitalisation (median 18 (IQR 12-30) vs 15 days (IQR 9.75-22.75), P=0.005) and had a higher mortality (8.4% vs 1.3%, P=0.041). When the oral diet was changed, we observed a lower pneumonia rate (36% vs 50%, P=0.051) and a lower mortality (3.7% vs 11.3%, P=0.043) in comparison to no change of oral diet. A restriction of oral diet was identified more often in older patients (median 75 years (IQR 66.3-82 years) vs median 72 years (IQR 60-79 years), P=0.01) and in patients with structural brain lesions (86.8% vs 73.1%, P=0.05). CONCLUSION: On clinical investigation, dysphagia was misjudged for the majority of the patients. FEES might help to compensate this drawback, revising the diet regime in nearly 70% of the patients.