Cognitive outcomes after unruptured intracranial aneurysm treatment with endovascular coiling.

BACKGROUND: We aimed to determine the effects of endovascular coiling of unruptured intracranial aneurysms (UIAs) on cognition to inform treatment decisions. We present the first study using the Montreal Cognitive Assessment (MoCA) to determine neurocognitive changes after endovascular coiling. METHODS: We prospectively collected data on all patients with UIAs undergoing endovascular coiling, primary or assisted. Patients completed the MoCA prior to intervention and 1 month and 6 months' post-procedure. A repeated measures linear mixed effects model was used to compare pre-procedure and post-procedure cognition. RESULTS: Thirty-three patients with 33 aneurysms who underwent coiling from April 2017 to May 2020 were included (mean age 55.5, 81.8% female). All procedures used general anesthesia. There was no difference between baseline and post-procedure MoCA scores at any time interval (P>0.05). Mean MoCA scores at baseline, 1 month post-procedure, and 6 months' post-procedure were 25.4, 26.8, and 26.3 respectively. There was also no difference between pre- and post-procedure scores on any individual MoCA domain (visuospatial, naming, memory, attention, language, abstraction, delayed recall, and orientation) at any time interval (P>0.05). Seventeen patients had follow-up MRI or CT imaging, of which 11.8% showed radiographic changes or ischemia. 77.8% of patients with 6-month angiographic follow-up achieved class I, and 22.2% achieved class II Raymond-Roy Occlusion. Thirty-two out of 33 patients had follow-up mRS ≤2. CONCLUSION: Our study suggests that endovascular coiling does not diminish neurocognitive function. Patients with UIAs in our cohort also had baseline MoCA scores below the cut-off for mild cognitive impairment despite pre-procedure mRS and NIHSS of 0.

[Parkinson's disease and it's look-alike].

The diagnosis of Parkinson's disease (PD) requires the exclusion of other diseases using various methods. However, it is difficult to differentiate these diseases based only on clinical symptoms, and information regarding responses to drugs and several imaging examinations are often needed for a diagnosis. In recent years, various neurological signs and symptoms have been reported that are particularly useful in neurological examinations for differentiating PD, progressive supranuclear palsy, and multiple system atrophy. Currently, diagnosis using imaging techniques and artificial intelligence are being developed, but systematic neurological examinations will continue to be important in diagnosing these diseases.

A new child-friendly 3D bimanual protocol to assess upper limb movement in children with unilateral cerebral palsy: Development and validation.

Unilateral cerebral palsy (uCP) causes upper limb movement disorders that impact on daily activities, especially in bimanual condition. However, a few studies have proposed bimanual tasks for 3D motion analysis. The aim of this study was to validate the new version of a child-friendly, 3D, bimanual protocol for the measurement of joint angles and movement quality variables. Twenty children with uCP and 20 typically developing children (TDC) performed the five-task protocol integrated into a game scenario. Each task specifically targeted one or two upper limb degrees of freedom. Joint angles, smoothness and trajectory straightness were calculated. Elbow extension, supination, wrist extension and adduction amplitudes were reduced; hand trajectories were less smooth and straight in children with uCP compared to TDC. Correlations between the performance-based score and kinematic variables were strong. High within and between-session reliability was found for most joint angle variables and lower reliability was found for smoothness and straightness in most tasks. The results therefore demonstrated the validity and reliability of the new protocol for the objective assessment of bimanual function in children with uCP. The evaluation of both joint angles and movement quality variables should increase understanding of pathological movement patterns and help clinicians to optimize treatment. ClinicalTrials.gov identifier: NCT03888443.

Telemedicine During COVID-19 and Beyond: A Practical Guide and Best Practices Multidisciplinary Approach for the Orthopedic and Neurologic Pain Physical Examination.

BACKGROUND: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare's 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience. OBJECTIVES: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine. STUDY DESIGN: Consensus-based multispecialty guidelines. SETTING: Tertiary care center. METHODS: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting. RESULTS: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests. LIMITATIONS: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed. CONCLUSIONS: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.

Video consultations in ordinary and extraordinary times.

Tele-neurology is a neurological consultation at a distance, or not in person, using various technologies to achieve connectivity, including the telephone and the internet. The telephone is ubiquitous and is a standard part of how we manage patients. Video consulting has been used for a long time in some centres, particularly in those where the geography means that patients have to travel long distances. Various technologies can be used, and with the development of various internet-based video-calling platforms, real-time video consulting has become much more accessible. We have provided a tele-neurology service in the North East of Scotland since 2006 using video conferencing with far-end camera control. More recently, we have complemented this using an internet-based platform (NHS Near Me). Here we outline the practicalities of video consulting in 'ordinary' times and comment on its use in the 'extraordinary' times of the coronavirus pandemic.

Telemedicine in the Era of Coronavirus Disease 2019 (COVID-19): A Neurosurgical Perspective.

Despite the substantial growth of telemedicine and the evidence of its advantages, the use of telemedicine in neurosurgery has been limited. Barriers have included medicolegal issues surrounding provider reimbursement, interstate licensure, and malpractice liability as well as technological challenges. Recently, the coronavirus disease 2019 (COVID-19) pandemic has limited typical evaluation of patients with neurologic issues and resulted in a surge in demand for virtual medical visits. Meanwhile, federal and state governments took action to facilitate the rapid implementation of telehealth programs, placing a temporary lift on medicolegal barriers that had previously limited its expansion. This created a unique opportunity for widespread telehealth use to meet the surge in demand for remote medical care. After initial hurdles and challenges, our experience with telemedicine in neurosurgery at Penn Medicine has been overall positive from both the provider and the patients' perspective. One of the unique challenges we face is guiding patients to appropriately set up devices in a way that enables an effective neuroexamination. However, we argue that an accurate and comprehensive neurologic examination can be conducted through a telemedicine platform, despite minor weaknesses inherent to absence of physical presence. In addition, certain neurosurgical visits such as postoperative checks, vascular pathology, and brain tumors inherently lend themselves to easier evaluation through telehealth visits. In the era of COVID-19 and beyond, telemedicine remains a promising and effective approach to continue neurologic patient care.

Sideline Concussion Assessment: The Current State of the Art.

More than 200 million American adults and children participate in organized physical activity. Growing awareness has highlighted that concussion, especially when repeated, may be associated with prolonged neurological, cognitive, and/or neuropsychiatric sequelae. Objective diagnosis of concussion remains challenging. Although some concussion symptoms may be apparent even to nonmedical observers, diagnosis and removal from play for evaluation depend on validated assessment tools and trained, vigilant healthcare personnel. Over the past 2 decades, sideline concussion measures have undergone significant revision and augmentation to become more comprehensive batteries in order to detect a wide spectrum of symptomatology, eg, neurocognitive function, postconcussive symptoms, gait/balance, and saccadic eye movements. This review summarizes the current state-of-the-art concussion evaluation instruments, ranging from the Sports Concussion Assessment Tool (SCAT) and tools that may enhance concussion detection, to near-term blood-based biomarkers and emerging technology (eg, head impact sensors, vestibulo-ocular/eye-tracking, and mobile applications). Special focus is directed at feasibility, utility, generalizability, and challenges to implementation of each measure on-field and on the sidelines. This review finds that few instruments beyond the SCAT provide guidance for removal from play, and establishing thresholds for concussion detection and removal from play in qualification/validation of future instruments is of high importance. Integration of emerging sideline concussion evaluation tools should be supported by resources and education to athletes, caregivers, athletic staff, and medical professionals for standardized administration as well as triage, referral, and prevention strategies. It should be noted that concussion evaluation instruments are used to assist the clinician in sideline diagnosis, and no single test can diagnose concussion as a standalone investigation.

12-Month stability of neurological soft signs in stabilized patients with schizophrenia.

Objective: Neurological soft signs (NSS) are a group of minor non-localizable neurological abnormalities found more often in patients with schizophrenia. The aim of the current study was to investigate their temporal stability and relationship to the overall outcome over a 12-month period. Material and methods: The study sample included 133 stabilized patients suffering from schizophrenia (77 males and 56 females; aged 33.55 ± 11.22 years old). The assessment included the application at baseline and after 12 months of the Neurological Evaluation Scale (NES), and a number of scales assessing the clinical symptoms and adverse effects. The statistical analysis included ANOVA, exploratory t-test and Pearson correlation coefficients with Bonferroni correction. Results: In stabilized patients, NSS are stable over a 12-month period with only the subscale of NES-sensory integration manifesting a significant worsening, while, in contrast, most of the clinical variables improved significantly. There was no relationship of NES scores with the magnitude of improvement. The only significant negative correlation was between NES-motor coordination and Positive and Negative Syndrome Scale-GP change at 1 year. Discussion: The results of the current study suggest that after stabilization of patients with schizophrenia, there are probably two separate components, a 'trait' which is stable over a 12-month period, and a 'degenerative' component with a tendency to worsen probably in parallel with the progression of the illness and in correlation with the worsening of negative symptoms. However, the statistical support of the 'degenerative' component is weak. Significant outcomes Neurological softs signs are stable over a 12-month period, with the exception of 'sensory integration' which manifests significant improvement irrespective of treatment response. They do not respond to treatment with antipsychotics. They do not constitute a prognostic factor to predict improvement over a period of 1 year. Neurological soft signs constitute a trait symptom of schizophrenia which is stable though time. Limitations All the subjects have been previously hospitalized which may represent a more severe form of schizophrenia. Also, all patients were under antipsychotic and some also under benzodiazepine medications. Patients with comorbid somatic disorders were excluded which may decrease generalizability of results.

Cerebral ischemia and deterioration with lower blood pressure target in intracerebral hemorrhage.

OBJECTIVE: To determine the incidence and predictors of acute cerebral ischemia and neurologic deterioration in intracerebral hemorrhage (ICH) patients after an institutional protocol change in systolic blood pressure (SBP) target from <160 to <140 mm Hg. METHODS: We retrospectively compared persons admitted with primary ICH before and after a protocol change in SBP target from <160 to <140 mm Hg. The primary outcomes were presence of acute cerebral ischemia on MRI completed within 2 weeks of ICH and acute neurologic deterioration. RESULTS: Of 286 persons with primary ICH, 119 underwent MRI and met inclusion criteria. Sixty-two had a target SBP <160 mm Hg (group 1) and 57 had a target SBP <140 mm Hg (group 2). There were no differences between the 2 groups in baseline clinical and radiographic characteristics, but over the first 24 hours of hospitalization, group 2 had lower mean SBP (134 vs 143 mm Hg, p < 0.001) and lower minimum SBP over 72 hours (106 vs 112 mm Hg, p = 0.02). Acute cerebral ischemia was more frequent in group 2 than in group 1 (32% vs 16%; p = 0.047) as was acute neurologic deterioration (19% vs 5%; p = 0.022). A minimum SBP ≤120 mm Hg over 72 hours was associated with cerebral ischemia, while no patient with a minimum SBP ≥130 mm Hg had cerebral ischemia. Acute cerebral ischemia was significantly associated with worse discharge NIH Stroke Scale score, while SBP target was not. CONCLUSIONS: Intensive lowering of SBP <140 mm Hg in acute ICH, particularly allowing SBP <120 mm Hg, is associated with increased remote cerebral ischemic lesions and acute neurologic deterioration.

Early Cranioplasty is Associated with Greater Neurological Improvement: A Systematic Review and Meta-Analysis.

BACKGROUND: Cranioplasty after decompressive craniectomy is a common neurosurgical procedure, yet the optimal timing of cranioplasty has not been well established. OBJECTIVE: To investigate whether the timing of cranioplasty is associated with differences in neurological outcome. METHODS: A systematic literature review and meta-analysis was performed using MEDLINE, Scopus, and the Cochrane databases for studies reporting timing and neurological assessment for cranioplasty after decompressive craniectomy. Pre- and postcranioplasty neurological assessments for cranioplasty performed within (early) and beyond (late) 90 d were extracted. The standard mean difference (SMD) was used to normalize all neurological measures. Available data were pooled to compare pre-cranioplasty, postcranioplasty, and change in neurological status between early and late cranioplasty cohorts, and in the overall population. RESULTS: Eight retrospective observational studies were included for a total of 528 patients. Studies reported various outcome measures (eg, Barthel Index, Karnofsky Performance Scale, Functional Independence Measure, Glasgow Coma Scale, and Glasgow Outcome Score). Cranioplasty, regardless of timing, was associated with significant neurological improvement (SMD .56, P = .01). Comparing early and late cohorts, there was no difference in precranioplasty neurological baseline; however, postcranioplasty neurological outcome was significantly improved in the early cohort (SMD .58, P = .04) and showed greater magnitude of change (SMD 2.90, P = .02). CONCLUSION: Cranioplasty may improve neurological function, and earlier cranioplasty may enhance this effect. Future prospective studies evaluating long-term, comprehensive neurological outcomes will be required to establish the true effect of cranioplasty on neurological outcome.

Neurological soft signs, dissociation and alexithymia in patients with obsessive-compulsive disorder (OCD) and healthy subjects.

A body of evidence has supported that patients with obsessive-compulsive disorder (OCD) have increased rates of various neurological soft signs (NSS) compared to controls. Various lines of research has documented robust relationships between OCD and dissociative symptomatology. The study aimed to examine the associations between obsessive-compulsive symptoms, dissociative experiences alexithymia, and NSS. The study included thirty OCD patients and thirty healthy controls, matched for age, marital status, education, and income. The Neurological Evaluation Scale (NES), Padua Inventory-Revised (PI-R), Dissociative Experiences Scale (DES) and Toronto Alexithymia Scale (TAS-20) were administered. In comparison to healthy controls, patients with OCD had difficulty sequencing for complex motor acts and greater absorption/ imaginative involvement. Using latent class analysis, the study sample was classified into two homogenous subsets as mild NSS (n = 45) and severe NSS (n = 15). Majority of the participants who were grouped into severe NSS latent class were OCD patient (n = 14, 93.3%). Furthermore, those with severe NSS reported greater levels of alexithymia and more severe obsessive-compulsive symptoms, particularly precision. We concluded that relationships between OCD severity and NSS appear to be of crucial importance. Our data along with accumulated evidence suggest that OCD associated with pronounced NSS may represent a specific subtype of the disorder.

How tandem gait stumbled into the neurological exam: a review.

Tandem gait testing is an integral part of the neurological exam. It is informative in a wide variety of disorders ranging from cerebellar disease to vestibular and peripheral neuropathies, parkinsonism, and other neurodegenerative conditions. We discuss the history and development of tandem gait testing as well as its technique, utility, and limitations in the assessment of neurological conditions. Tandem gait has emerged as a tool in the assessment of cerebellar disease, Huntington disease, idiopathic Parkinson's disease, atypical parkinsonism, peripheral neuropathies, and vestibulopathies. Its origin can be deduced from experimental observation and clinical experience as far back as the early nineteenth century. Despite the long history and ubiquitous performance of tandem gait testing, there is no standardized, guideline-based protocol to model for more homogenous research and clinical practices. Such a protocol should be developed using historical texts and manuscripts as well as the consensus of the medical research community. With standard protocols, further studies could define the sensitivity of abnormal tandem gait testing in cerebellar disorders, more diffuse neurodegeneration, and peripheral pathologies. Tandem gait can be a useful marker of dysfunction in neurologic conditions whose pathologies extend beyond the vermis or vestibulocerebellar module to include interconnected networks throughout the nervous system.

Recent developments in the management of patients resuscitated from cardiac arrest.

Cardiac arrest is the leading cause of death in Europe and the United States. Many patients who are initially resuscitated die in the hospital, and hospital survivors often have substantial neurologic dysfunction. Most cardiac arrests are caused by coronary artery disease; patients with coronary artery disease likely benefit from early coronary angiography and intervention. After resuscitation, cardiac arrest patients remain critically ill and frequently suffer cardiogenic shock and multiorgan failure. Early cardiopulmonary stabilization is important to prevent worsening organ injury. To achieve best patient outcomes, comprehensive critical care management is needed, with primary goals of stabilizing hemodynamics and preventing progressive brain injury. Targeted temperature management is frequently recommended for comatose survivors of cardiac arrest to mitigate the neurologic injury that drives outcomes. Accurate neurologic assessment is central to managing care of cardiac arrest survivors and should combine physical examination with objective neurologic testing, with the caveat that delaying neurologic prognosis is essential to avoid premature withdrawal of supportive care. A combination of clinical findings and diagnostic results should be used to estimate the likelihood of functional recovery. This review focuses on recent advances in care and specific cardiac intensive care strategies that may improve morbidity and mortality for patients after cardiac arrest.

The use of neurodiagnostic technologies in the 21st century neuroscientific revolution.

Neuroscience is fascinating, mysterious, and truly medicine's "final frontier" but deciphering its marvels has historically been inhibited by its sheer complexity. The recent escalation of global neuroscientific endeavors and vast financial backing from governments, foundations, and industries, however are changing this perspective. The sequencing of the human genome, development of innovative tools for mapping neuronal connectivities, and enhanced resolution capabilities of imaging techniques have made landmark contributions toward advancing neurotechnologies. Nations all around the world have initiated and launched brain mapping projects on such a profound and financially immense scale that research in 2015 and beyond are highly anticipated to revolutionize medicine and our interaction with the technological world. Although neurodiagnostic technology is not the vanguard of research interest in the scientific community, it will certainly ride the coattails of these new neuroscientific endeavors. And, in turn, these advancements will greatly impact how we diagnose, treat, and care for our patients in the future. Therefore, the purpose of this article is not only to introduce current neuroscientific enterprises, but to also explore some of the most interesting and instrumental findings using neurodiagnostic technology over the past year.

Predictive factors for pacemaker implantation in patients receiving an implantable loop recorder for syncope remained unexplained after an extensive cardiac and neurological workup.

BACKGROUND: Several previous implantable loop recorder (ILR) studies have shown bradyarrhythmic events requiring a pacemaker implantation in a significant proportion of patients with unexplained syncope (US). The aim of this observational, two-centre, study was to identify the predictive factors for pacemaker implantation in a population of patients receiving an ILR for US with suspected arrhythmic aetiology. METHODS: Fifty-six patients (mean age 68 years, 61% male) with a history of US and negative cardiac and neurological workup, who underwent ILR implantation, were enrolled. After the implantation, a follow-up visit was undertaken after symptomatic events or every 3 months in asymptomatic subjects. The end-point of the study was the detection of a bradyarrhythmia (with or without a syncopal recurrence) requiring pacemaker implantation. RESULTS: After a median ILR observation of 22 months, a clinically significant bradyarrhythmia was detected in 11 patients (20%), of which 9 cases related to syncopal relapses. In the multivariable analysis, three independent predictive factors for pacemaker implantation were identified: an age >75 years (odd ratio [OR]: 29.9; p=0.035); a history of trauma secondary to syncope (OR: 26.8; p=0.039); and the detection of periods of asymptomatic bradycardia, not sufficient to explain the mechanism of syncope, during conventional ECG monitoring (through 24 h Holter or in hospital telemetry), performed before ILR implantation (OR: 24.7; p=0.045). CONCLUSIONS: An advanced age, a history of trauma secondary to syncope, and the detection of periods of asymptomatic bradycardia during conventional ECG monitoring were independent predictive factors for bradyarrhythmias requiring pacemaker implantation in patients receiving an ILR for US.