Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 89
Filtrar
1.
Rev Neurosci ; 2024 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-38581271

RESUMO

Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.

2.
Neurosurg Rev ; 47(1): 40, 2024 Jan 10.
Artigo em Inglês | MEDLINE | ID: mdl-38200247

RESUMO

Intraventricular hemorrhage (IVH) is a complication of a spontaneous intracerebral hemorrhage. Standard treatment is with external ventricular drain (EVD). Intraventricular thrombolysis may improve mortality but does not improve functional outcomes. We present our initial experience with a novel irrigating EVD (IRRAflow) that automates continuous irrigation with thrombolysis.Single-center case-control study including patients with IVH treated with EVD compared to IRRAflow. We compared standard demographics, treatment, and outcome parameters between groups. We developed a brain phantom injected with a human clot and assessed clot clearance using EVD/IRRAflow approaches with CT imaging.Twenty-one patients were treated with standard EVD and 9 patients with IRRAflow. Demographics were similar between groups. Thirty-three percent of patients with EVD also had at least one dose of t-PA and 89% of patients with IRRAflow received irrigation with t-PA (p = 0.01). Mean drain days were 8.8 for EVD versus 4.1 for IRRAflow (p = 0.02). Days-to-clearance of ventricular outflow was 5.8 for EVD versus 2.5 for IRRAflow (p = 0.02). Overall clearance was not different. Thirty-seven percent of EVD patients achieved good outcome (mRS ≥ 3) at 90 days versus 86% of IRRAflow patients (p = 0.03). Assessing only t-PA, reduction in mean days-to-clearance (p = 0.0004) and ICU days (p = 0.04) was observed. In the benchtop model, the clot treated with IRRAflow and t-PA showed a significant reduction of volume compared to control.Irrigation with IRRAflow and t-PA is feasible and safe for patients with IVH. Improving clot clearance with IRRAflow may result in improved clinical outcomes and should be incorporated into randomized trials.


Assuntos
Hemorragia Cerebral , Fibrinolíticos , Humanos , Estudos de Casos e Controles , Fibrinolíticos/uso terapêutico , Hemorragia Cerebral/tratamento farmacológico , Hemorragia Cerebral/cirurgia , Encéfalo
3.
World Neurosurg ; 182: 165-183.e1, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38006933

RESUMO

OBJECTIVE: This study was conducted to systematically analyze the data on the clinical features, surgical treatment, and outcomes of spinal schwannomas. METHODS: We conducted a systematic review and meta-analysis under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of bibliographic databases from January 1, 2001, to May 31, 2021, yielded 4489 studies. Twenty-six articles were included in our final qualitative systematic review and quantitative meta-analysis. RESULTS: Analysis of 2542 adult patients' data from 26 included studies showed that 53.5% were male, and the mean age ranged from 35.8 to 57.1 years. The most common tumor location was the cervical spine (34.2%), followed by the thoracic spine (26.2%) and the lumbar spine (18.5%). Symptom severity was the most common indicator for surgical treatment, with the most common symptoms being segmental back pain, sensory/motor deficits, and urinary dysfunction. Among all patients analyzed, 93.8% were treated with gross total resection, which was associated with better prognosis and less chance of recurrence than subtotal resection. The posterior approach was the most common (87.4% of patients). The average operative time was 4.53 hours (95% confidence interval [CI], 3.18-6.48); the average intraoperative blood loss was 451.88 mL (95% CI, 169.60-1203.95). The pooled follow-up duration was 40.6 months (95% CI, 31.04-53.07). The schwannoma recurrence rate was 5.3%. Complications were particularly low and included cerebrospinal fluid leakage, wound infection, and the sensory-motor deficits. Most of the patients experienced complete recovery or significant improvement of preoperative neurological deficits and pain symptoms. CONCLUSIONS: Our analysis suggests that segmental back pain, sensory/motor deficits, and urinary dysfunction are the most common symptoms of spinal schwannomas. Surgical resection is the treatment of choice with overall good reported outcomes and particularly low complication rates. gross total resection offers the best prognosis with the slightest chance of tumor recurrence and minimal risk of complications.


Assuntos
Recidiva Local de Neoplasia , Neurilemoma , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Resultado do Tratamento , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/cirurgia , Recidiva Local de Neoplasia/etiologia , Neurilemoma/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Dor nas Costas/etiologia , Dor nas Costas/cirurgia , Estudos Retrospectivos
4.
J Neurosurg ; 139(4): 1036-1041, 2023 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-37856891

RESUMO

OBJECTIVE: The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) remains one of the most important targets for neurocritical care. Advances in monitoring technology have facilitated a more thorough understanding of the pathophysiology and therapeutic approaches, but interventions are generally limited to either systemic therapies or passive CSF drainage. The authors present a novel approach that combines a multimodal monitoring bolt-based system with an irrigating ventricular drain capable of delivering intrathecal medications and describe their early experience in patients with aSAH. METHODS: The authors performed a retrospective review of cases treated with the combined Hummingbird multimodal bolt system and the IRRAflow irrigating ventriculostomy. RESULTS: Nine patients were treated with the combined multimodal bolt system with irrigating ventriculostomy approach. The median number of days to clearance of the third and fourth ventricles was 3 days in patients with obstructive intraventricular hemorrhage. Two patients received intrathecal alteplase for intraventricular hemorrhage clearance, and 2 patients received intrathecal nicardipine as rescue therapy for severe symptomatic angiographic vasospasm. CONCLUSIONS: Combined CSF drainage, irrigation, multimodality monitoring, and automated local drug delivery are feasible using a single twist-drill hole device. Further investigation of irrigation settings and treatment approaches in high-risk cases is warranted.


Assuntos
Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Humanos , Hemorragia Subaracnóidea/terapia , Hemorragia Subaracnóidea/tratamento farmacológico , Resultado do Tratamento , Nicardipino , Ativador de Plasminogênio Tecidual/uso terapêutico , Drenagem , Hemorragia Cerebral/tratamento farmacológico , Vasoespasmo Intracraniano/tratamento farmacológico , Vasoespasmo Intracraniano/etiologia
5.
Br J Neurosurg ; 37(1): 67-70, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34569389

RESUMO

BACKGROUND AND PURPOSE: The utility of preoperative embolization remains controversial within the literature. Here, we evaluate whether preoperative meningioma embolization is effective in reducing intraoperative blood loss, safe to perform, and cost-effective when compared with surgical resection without preoperative embolization. METHODS: Twenty-nine patients with meningiomas were matched by tumor size and location to 29 control patients with meningiomas at another institution where preoperative embolization was not practiced. The variables evaluated were pre- and post-operative hemoglobin and hematocrit levels as a measure of operative blood loss and postoperative morbidity. The additional cost of undergoing angiography and embolization was calculated from hospital charges obtained from the billing department. RESULTS: The mean decrease in perioperative hemoglobin and hematocrit was 0.9 and 2.7, respectively, in the embolization group and 2.8 and 10.0, respectively, in the control group for a significant decrease in operative blood loss as measured by change in hematocrit and hemoglobin levels after surgery. There was no significant difference in operative blood loss when subdividing patients based on tumor location. There were no angiogram-related complications. Twenty-two of 29 patients (76%) underwent embolization of a feeding artery, whereas 7 patients underwent only a diagnostic angiogram. The mean additional charge per patient in the embolization group was $88,767. CONCLUSIONS: Preoperative embolization was safe and effective in reducing the overall perioperative blood loss in patients undergoing meningioma resection, as measured by the change in postoperative hemoglobin and hematocrit levels. However, the cost of embolization was significant.


Assuntos
Embolização Terapêutica , Neoplasias Meníngeas , Meningioma , Humanos , Meningioma/cirurgia , Neoplasias Meníngeas/cirurgia , Estudos Retrospectivos , Perda Sanguínea Cirúrgica/prevenção & controle , Estudos de Casos e Controles , Cuidados Pré-Operatórios
6.
World J Orthop ; 13(5): 528-537, 2022 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-35633740

RESUMO

BACKGROUND: Femoral shaft fracture is a commonly encountered orthopedic injury that can be treated operatively with a low overall delayed/nonunion rate. In the case of delayed union after antegrade or retrograde intramedullary nail fixation, fracture dynamization is often attempted first. Nonunion after dynamization has been shown to occur due to infection and other aseptic etiologies. We present a unique case of diaphyseal femoral shaft fracture nonunion after dynamization due to intramedullary cortical bone pedestal formation at the distal tip of the nail. CASE SUMMARY: A 37-year-old male experienced a high-energy trauma to his left thigh after coming down hard during a motocross jump. Evaluation was consistent with an isolated, closed, left mid-shaft femur fracture. He was initially managed with reamed antegrade intramedullary nail fixation but had continued thigh pain. Radiographs at four months demonstrated no evidence of fracture union and failure of the distal locking screw, and dynamization by distal locking screw removal was performed. The patient continued to have pain eight months after the initial procedure and 4 mo after dynamization with serial radiographs continuing to demonstrate no evidence of fracture healing. The decision was made to proceed with exchange nailing for aseptic fracture nonunion. During the exchange procedure, an obstruction was encountered at the distal tip of the failed nail and was confirmed on magnified fluoroscopy to be a pedestal of cortical bone in the canal. The obstruction required further distal reaming. A longer and larger diameter exchange nail was placed without difficulty and without a distal locking screw to allow for dynamization at the fracture site. Post-operative radiographs showed proper fracture and hardware alignment. There was subsequently radiographic evidence of callus formation at one year with subsequent fracture consolidation and resolution of thigh pain at eighteen months. CONCLUSION: The risk of fracture nonunion caused by intramedullary bone pedestal formation can be mitigated with the use of maximum length and diameter nails and close follow up.

7.
J Neurosurg Sci ; 2022 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-35416459

RESUMO

BACKGROUND: Traumatic spinal injury (TSI) can lead to severe morbidity and significant health care resource utilization. Intraoperative navigation (ION) systems have been shown to improve outcomes in some populations. However, controversy about the benefit of ION remains. To our knowledge, there is no large database analysis studying the outcomes of ION on TSI patients. Here we hope to compare complications and outcomes in patients with TSI undergoing spinal fusion of 3 or more levels with or without the use of ION. METHODS: The 2015-2019 National Surgical Quality Improvement Program (NSQIP) database was queried for cases of posterior spinal instrumentation of 3 or more levels. This population was then selected for postoperative diagnosis consistent with TSI. The effect of prolonged operative time was analyzed for all patients. Propensity score matching analysis was performed to create ION case and non-ION control groups. Baseline demographic characteristics, complications, and outcome data were collected and compared between ION and non-ION groups. RESULTS: A total of 1,034 patients were included in the propensity matched analysis. Among comorbidities, only obesity was significantly more likely in the non-ION group. There was no difference in case complexity between the two groups. ION was associated with higher incidence of prolonged operative time but was a negative independent predictor for sepsis. Prolonged operative time was a significant independent predictor for pulmonary embolism and requirement of transfusion in all patients. Discharge to home, readmission, and reoperation rates did not differ between TSI patients with or without ION. CONCLUSIONS: Use of ION during posterior spinal fusion of 3 or more levels in TSI patients is not associated with worse outcomes. Prolonged operative time, rather than ION, appears to have a higher influence on the rate of complications in this population. Evaluation of ION in the context of specific populations and pathology is warranted to optimize its use.

8.
Eur J Surg Oncol ; 48(7): 1671-1677, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35216859

RESUMO

PURPOSE: The objective of this study was to compare the effect of frailty, as measured by the 5-factor modified frailty index (mFI-5), with that of age on postoperative outcomes of patients undergoing surgery for intracranial meningiomas, using data from a large national registry. METHODS: The National Surgical Quality Improvement Program (NSQIP) database (2015-2019) was queried to analyze data from patients undergoing intracranial meningioma resection (N = 5,818). Univariate and multivariate analyses of age and mFI-5 score were performed for 30-day mortality, major complications, unplanned reoperation, unplanned readmission, extended hospital length of stay (eLOS), and discharge to a non-home destination. RESULTS: Both univariate and multivariate analyses (adjusted for sex, body mass index, transfer status, smoking, and operative time) demonstrated that mFI-5 and age were significant predictors of adverse postoperative outcomes in patients with intracranial meningioma. However, based on odds ratios (OR) and effect sizes, increasing frailty tiers were better predictors than age of adverse outcomes. Severely frail patients showed highest effects sizes for all postoperative outcome variables [OR 11.17 (95% CI 3.45-36.19), p<0.001 for mortality; OR 4.15 (95% CI 2.46-6.99), p<0.001 for major complications; OR 4.37 (95% CI 2.68-7.12), p<0.001 for unplanned readmission; OR 2.31 (95% CI 1.17-4.55), p<0.001 for unplanned reoperation; OR 4.28 (95% CI 2.74-6.68), p<0.001 for eLOS; and OR 9.34 (95% CI 6.03-14.47, p<0.001) for discharge other than home. CONCLUSION: In this national database study, baseline frailty status was a better independent predictor for worse postoperative outcomes than age in patients with intracranial meningioma.


Assuntos
Fragilidade , Neoplasias Meníngeas , Meningioma , Fragilidade/complicações , Fragilidade/epidemiologia , Humanos , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Melhoria de Qualidade , Estudos Retrospectivos , Fatores de Risco
9.
World Neurosurg ; 161: e347-e354, 2022 05.
Artigo em Inglês | MEDLINE | ID: mdl-35134588

RESUMO

PURPOSE: Increasing patient age has been associated with worse outcomes after pituitary adenoma resection in previous studies, but the prognostic value of frailty compared with advancing age on pituitary adenoma resection outcomes has not been clearly evaluated. METHODS: The National Surgical Quality Improvement Program from 2015 to 2019 was queried for data for patients aged >18 years who underwent pituitary adenoma resection (n = 1454 identified patients). Univariate and multivariate analyses of age and frailty (5-factor modified frailty index [mFI-5]) were performed on 30-day mortality, major complications, extended length of stay (eLOS), discharge destination, and readmission and reoperation. The receiver operating characteristic curve analysis was performed to compare effect of age and mFI-5. RESULTS: On univariate analysis, increasing frailty was significantly associated with greater risk of unplanned readmission (frail: odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2-3.2; severely frail: OR, 6.9; 95% CI, 2.4-19.8) and a major complication (frail: OR, 3.6; 95% CI, 2.1-6.1). Severe frailty was also associated with nonhome discharge (OR, 10.6; 95% CI, 3.2-35.8) and eLOS (OR, 4.5; 95% CI, 1.5-13.4). Increasing age was not associated with any of these outcome measures. Multivariate analysis also demonstrated similar trends. In receiver operating characteristic curve analysis, the mFI-5 score showed higher discrimination for major complications compared with age (area under the curve: 0.624 vs. 0.503; P < 0.001). CONCLUSION: Increasing frailty, and not advancing age, was an independent predictor for major complications, unplanned readmissions, eLOS, and nonhome discharge after pituitary adenoma resection, suggesting frailty to be superior to age in preoperative risk stratification in this patient population.


Assuntos
Adenoma , Fragilidade , Neoplasias Hipofisárias , Adenoma/cirurgia , Humanos , Readmissão do Paciente , Neoplasias Hipofisárias/cirurgia , Resultado do Tratamento
10.
Neurospine ; 19(1): 53-62, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-35130424

RESUMO

OBJECTIVE: The present study aimed to evaluate the effect of baseline frailty status (as measured by modified frailty index-5 [mFI-5]) versus age on postoperative outcomes of patients undergoing surgery for spinal tumors using data from a large national registry. METHODS: The National Surgical Quality Improvement Program database was used to collect spinal tumor resection patients' data from 2015 to 2019 (n = 4,662). Univariate and multivariate analyses for age and mFI-5 were performed for the following outcomes: 30-day mortality, major complications, unplanned reoperation, unplanned readmission, hospital length of stay (LOS), and discharge to a nonhome destination. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative performance of age versus mFI-5. RESULTS: Both univariate and multivariate analyses demonstrated that mFI-5 was a more robust predictor of worse postoperative outcomes as compared to age. Furthermore, based on categorical analysis of frailty tiers, increasing frailty was significantly associated with increased risk of adverse outcomes. 'Severely frail' patients were found to have the highest risk, with odds ratio 16.4 (95% confidence interval [CI],11.21-35.44) for 30-day mortality, 3.02 (95% CI, 1.97-4.56) for major complications, and 2.94 (95% CI, 2.32-4.21) for LOS. In ROC curve analysis, mFI-5 score (area under the curve [AUC] = 0.743) achieved superior discrimination compared to age (AUC = 0.594) for mortality. CONCLUSION: Increasing frailty, as measured by mFI-5, is a more robust predictor as compared to age, for poor postoperative outcomes in spinal tumor surgery patients. The mFI-5 may be clinically used for preoperative risk stratification of spinal tumor patients.

11.
J Stroke Cerebrovasc Dis ; 31(5): 106394, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35193027

RESUMO

OBJECTIVES: Aneurysmal subarachnoid hemorrhage (aSAH) is an emergent neurosurgical condition associated with high morbidity and mortality. The prognostic significance of baseline frailty status in aSAH patients has not been previously evaluated in a large, nationally representative sample. MATERIALS AND METHODS: Clinical outcomes data from the National Inpatient Sample from 2010-2018 were compared among sub-cohorts stratifying admissions by increasing frailty thresholds [(assessed using the 11-point modified frailty index (mFI-11)]. The previously validated NIS-SAH Severity Score (NIS-SSS) and NIS-SAH Outcome Measure (NIS-SOM) were utilized. Complex samples multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were performed to assess adjusted associations and discrimination of frailty for endpoints. RESULTS: Among 64,102 aSAH hospitalizations (mean age 55.4 years), 20.4% of admissions were classified as robust (mFI=0), 43.4% as pre-frail (mFI = 1), 24.9% as frail (mFI = 2), and 11.2% as severely frail (mFI ≥ 3). Following multivariable analysis adjusting for age and aSAH severity, increasing frailty was independently associated with NIS-SOM (OR = 1.15, 95% CI 1.09-1.21; p < 0.001), extended length of hospital stay (eLOS) (OR = 1.08, 1.02-1.13; p = 0.008), neurological complications (OR = 1.08, 1.03-1.13; p < 0.001), and medical complications (OR = 1.14, 1.08-1.21; p < 0.001). Based on ROC curve analysis, frailty achieved an AUC of 0.59 (0.58-0.60) and 0.54 (0.53-0.55) for NIS-SOM and eLOS, respectively. Age and NIS-SSS demonstrated significantly greater discrimination for NIS-SOM [AUC 0.69 (0.68-0.70) and 0.79 (0.78-0.80), respectively), while NIS-SSS achieved significantly greater discrimination for eLOS [(AUC 0.74 (0.73-0.75)] in comparison to both age and frailty. CONCLUSIONS: This national database evaluation of frailty in aSAH patients demonstrates an independent association between increasing frailty and poor functional outcome. Age and aSAH severity, however, may be more robust prognostic factors.


Assuntos
Fragilidade , Hemorragia Subaracnóidea , Fragilidade/complicações , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Hospitalização , Humanos , Pacientes Internados , Tempo de Internação , Pessoa de Meia-Idade , Estudos Retrospectivos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapia , Resultado do Tratamento
12.
Postgrad Med J ; 98(1158): 239-245, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33632761

RESUMO

There has been extensive research into methods of increasing academic departmental scholarly activity (DSA) through targeted interventions. Residency programmes are responsible for ensuring sufficient scholarly opportunities for residents. We sought to discover the outcomes of an intensive research initiative (IRI) on DSA in our department in a short-time interval. IRI was implemented, consisting of multiple interventions, to rapidly produce an increase in DSA through resident/medical student faculty engagement. We compare pre-IRI (8 years) and post-IRI (2 years) research products (RP), defined as the sum of oral presentations and publications, to evaluate the IRI. The study was performed in 2020. The IRI resulted in an exponential increase in DSA with an annual RP increase of 350% from 2017 (3 RP) to 2018 (14 RP), with another 92% from 2018 (14 RP) to 2019 (27 RP). RP/year exponentially increased from 2.1/year to 10.5/year for residents and 0.5/year to 10/year for medical students, resulting in a 400% and 1900% increase in RP/year, respectively. The common methods in literature to increase DSA included instituting protected research time (23.8%) and research curriculum (21.5%). We share our department's increase in DSA over a short 2-year period after implementing our IRI. Our goal in reporting our experience is to provide an example for departments that need to rapidly increase their DSA. By reporting the shortest time interval to achieve exponential DSA growth, we hope this example can support programmes in petitioning hospitals and medical colleges for academic support resources.


Assuntos
Pesquisa Biomédica , Internato e Residência , Neurocirurgia , Pesquisa Biomédica/educação , Currículo , Docentes de Medicina , Humanos
13.
Br J Neurosurg ; 36(3): 298-306, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32924623

RESUMO

False localizing signs (FLS) and other misleading neurological signs have long been an intractable aspect of neurocritical care. Because they suggest an incorrect location or etiology of the pathological lesion, they have often led to misdiagnosis and mismanagement of the patient. Here, we reviewed the existing literature to provide an updated, comprehensive descriptive review of these difficult to diagnose signs in neurocritical care. For each sign presented, we discuss the non-false localizing presentation of symptoms, the common FLS or misleading presentation, etiology/pathogenesis of the sign, and diagnosis, as well as any other clinically relevant considerations. Within cranial neuropathies, we cover cranial nerves III, IV, V, VI, VII, VIII, as well as multiple cranial nerve involvement of IX, X, and XII. FLS ophthalmologic symptoms indicate diagnostically challenging neurological deficits, and here we discuss downbeat nystagmus, ping-pong-gaze, one-and-a-half syndrome, and wall-eyed bilateral nuclear ophthalmoplegia (WEBINO). Cranial herniation syndromes are integral to any discussion of FLS and here we cover Kernohan's notch phenomenon, pseudo-Dandy Walker malformation, and uncal herniation. FLS in the spinal cord have also been relatively well documented, but in addition to compressive lesions, we also discuss newer findings in radiculopathy and disc herniation. Finally, pulmonary syndromes may sometimes be overlooked in discussions of neurological signs but are critically important to recognize and manage in neurocritical care, and here we discuss Cheyne-Stokes respiration, cluster breathing, central neurogenic hyperventilation, ataxic breathing, Ondine's curse, and hypercapnia. Though some of these signs may be rare, the framework for diagnosing and treating them must continue to evolve with our growing understanding of their etiology and varied presentations.


Assuntos
Doenças dos Nervos Cranianos , Doenças dos Nervos Cranianos/diagnóstico , Humanos , Paralisia , Medula Espinal
15.
Spinal Cord Ser Cases ; 7(1): 103, 2021 12 03.
Artigo em Inglês | MEDLINE | ID: mdl-34862363

RESUMO

INTRODUCTION: The alar ligament is an important structure in restraining the rotational movement at the atlantoaxial joint. While bony fractures generally heal, rupture of ligaments may heal poorly in adults and often requires surgical stabilization. Atlantoaxial rotatory subluxation (AARS) is a rare injury in adults, and the prognostic importance of the presence of alar ligament injury with regard to the success of nonoperative management is unknown. CASE PRESENTATION: A 28-year-old woman presented after a traumatic Type I AARS without evidence of osseous injury, but MRI demonstrated evidence of unilateral alar ligament disruption. Initial conservative management with closed reduction and maintenance in a rigid cervical collar proved unsuccessful, with worsening pain and failure to maintain reduction. She subsequently underwent open reduction and surgical fixation of C1-C2, resulting in resolution of her pain and maintenance of alignment. DISCUSSION: Alar ligament rupture may be a negative prognostic indicator in the success of nonoperative management of type I atlantoaxial rotatory subluxation. Additional study is warranted to better assess whether the status of the alar ligament should be considered an important factor in the management algorithm of type I AARS.


Assuntos
Articulação Atlantoaxial , Luxações Articulares , Adulto , Articulação Atlantoaxial/diagnóstico por imagem , Articulação Atlantoaxial/cirurgia , Tratamento Conservador , Feminino , Humanos , Luxações Articulares/cirurgia , Luxações Articulares/terapia , Ligamentos , Imageamento por Ressonância Magnética
16.
J Clin Neurosci ; 94: 70-75, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34863465

RESUMO

Middle meningeal artery (MMA) embolization represents a promising novel treatment modality for chronic subdural hematoma (cSDH), yet utilization and efficacy data are limited. This study evaluates the utilization and short-term outcomes of MMA embolization for cSDH treatment in a large national inpatient registry. cSDH patients treated with MMA embolization and/or surgical evacuation (craniotomy/burr hole drainage) were identified using the National Inpatient Sample (NIS) during 2012-2018 period. Temporal trends, complications, and discharge disposition were evaluated, and propensity score matching was implemented for adjusted comparisons and to mitigate confounding by indication. Among 60,045 cSDH patients identified, 390 (0.6%) underwent MMA embolization. Embolized patients presented more with high acute illness severity subclasses in comparison with surgically evacuated patients (53% vs. 34%, p = 0.004) yet did not experience any procedure-related hemorrhagic or ischemic complications. Although discharge disposition did not differ from those surgically managed, embolized patients had longer mean hospital stays (13 vs. 8 days, p = 0.023) and accrued greater hospital charges (p < 0.001). Following propensity adjustment, length of stay and charges remained greater in the embolization cohort, yet rates of routine discharge increased appreciably (40% vs. 30%, p = 0.141) relative to surgically treated cSDH patients. The utilization of embolization increased exponentially after 2015, reaching an apex in 2018 (3.7% of treated cSDH). This population-based national assessment demonstrates exponential increases in utilization of MMA embolization for cSDH treatment in recent years. Embolized patients had uncomplicated clinical courses and similar discharge dispositions as surgical evacuation patients. Large-scale prospective trials are warranted to further assess the efficacy of this modality.


Assuntos
Embolização Terapêutica , Hematoma Subdural Crônico , Hematoma Subdural Crônico/cirurgia , Humanos , Artérias Meníngeas/diagnóstico por imagem , Estudos Prospectivos , Resultado do Tratamento
17.
Cureus ; 13(11): e19837, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34963851

RESUMO

Bell's palsy is a relatively rare neurologic disorder with a limited selection of helpful therapies. This case report describes the author's initial three-month experience living with severe Bell's palsy, including a detailed history and timeline of the initial development of symptoms, treatments pursued, and psychological stress during the disease progression. A particular focus is placed on the emotional burden Bell's palsy can have, exploring possible avenues to improve physician to patient education on mental health and well-being during initial and delayed recovery.

18.
Cureus ; 13(9): e17868, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34660069

RESUMO

Introduction Interhospital transfer (IHT) contributes to increasing health care costs and typically accounts for increased patient morbidity and mortality compared to non-IHT patients. IHT inefficiencies leave patients vulnerable to delayed care and subsequent poor outcomes. In this study, we investigated factors influencing IHT of patients undergoing intracranial tumor resection (ITR), by comparing the variables distinguishing IHTs from non-IHT patients. Methods We performed a single-center retrospective review comparing IHT and non-IHT patients undergoing ITR from 2016 to 2018. Study variables included age, sex, race, the Milan Complexity Scale (MCS) score, 11-factor modified frailty index (mFI-11), length of stay (LOS), and Clavien-Dindo Score (CDS). Chi-square and Mann-Whitney U tests were used to identify significant differences in these variables between groups, while variables predictive of transfer status were identified using binary logistic regression. Results Data were collected from 219 patients undergoing ITR, with 80 (36.5%) IHT patients overall. The average age was 52 years (SD 18) and 57.7% were men. The MCS score was significantly higher in the IHT group (p = 0.014); however, mFI-11 was not (p = 0.322). The MCS score was predictive of IHT status in regression analysis (OR 1.17, p = 0.034). The IHT patients had a longer LOS (12 days vs 8 days, p = 0.014) with a lower CDS (p = 0.02). Conclusion The transfer patients for intracranial tumor resection had a higher MCS score and thus comprised a more surgically challenging population compared to non-transfer patients. As expected, IHT patients had a longer LOS as they lived further from hospital by definition.

19.
Cureus ; 13(8): e17104, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34527490

RESUMO

Background Despite their devastating nature, injuries due to tree-related- traumas are sparsely reported in the literature. Over the last several years, the incidence of tree-related traumatic injuries presenting to our level one trauma center, in Westchester, New York, has been concerning. The present study was undertaken to evaluate the clinical presentation, injury pattern, and outcomes of tree-related neurotrauma at our institution. In addition, we describe the injury pattern and medical management of several relevant cases of tree-related neurotrauma. Methods We conducted a retrospective analysis of tree-related neurotrauma over a five-year period from January of 2014 to March of 2019 at Westchester Medical Center (WMC) and Maria Fareri Children's Hospital, a level one trauma center. Patients presenting with neurotrauma that necessitated neurosurgical care were eligible for inclusion in this case series. Tree-related injury was defined as any trauma that was sustained as a direct result of collision with a tree. Results We identified 21 patients who sustained tree-related trauma. The cohort age ranged from 15 to 68 (mean=38 years). Injuries included seven skull fractures, four cases of subdural hematoma (SDH), six cases of intracranial hemorrhagic contusion, 14 spinal fractures, three cases of epidural hematoma (EDH), one case of spinal cord contusion, three vascular injuries, one case of dural laceration, and one case of pneumocephalus, with several patients suffering multiple injuries. Of the 21 patients, seven were female, and 12 were injured when their motor vehicle struck a tree. All but four patients were taken to the operating room for neurosurgical treatment, and nine of 21 patients were taken emergently to the operating room upon arrival. Conclusion The potential for serious head injuries with long-term neurologic sequelae exists with tree-related trauma. Clinicians should be advised of the challenging management of injuries secondary to tree-related trauma, and a greater emphasis should be placed on raising awareness of these accidental, but devastating injuries. Finally, a great majority of these injuries can be prevented or reduced in severity through helmet use and by adhering to safety guidelines.

20.
Mol Neurobiol ; 58(11): 5494-5516, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34341881

RESUMO

Spinal cord injury (SCI) is a devastating condition that affects approximately 294,000 people in the USA and several millions worldwide. The corticospinal motor circuitry plays a major role in controlling skilled movements and in planning and coordinating movements in mammals and can be damaged by SCI. While axonal regeneration of injured fibers over long distances is scarce in the adult CNS, substantial spontaneous neural reorganization and plasticity in the spared corticospinal motor circuitry has been shown in experimental SCI models, associated with functional recovery. Beneficially harnessing this neuroplasticity of the corticospinal motor circuitry represents a highly promising therapeutic approach for improving locomotor outcomes after SCI. Several different strategies have been used to date for this purpose including neuromodulation (spinal cord/brain stimulation strategies and brain-machine interfaces), rehabilitative training (targeting activity-dependent plasticity), stem cells and biological scaffolds, neuroregenerative/neuroprotective pharmacotherapies, and light-based therapies like photodynamic therapy (PDT) and photobiomodulation (PMBT). This review provides an overview of the spontaneous reorganization and neuroplasticity in the corticospinal motor circuitry after SCI and summarizes the various therapeutic approaches used to beneficially harness this neuroplasticity for functional recovery after SCI in preclinical animal model and clinical human patients' studies.


Assuntos
Plasticidade Neuronal , Tratos Piramidais/fisiopatologia , Traumatismos da Medula Espinal/fisiopatologia , Animais , Interfaces Cérebro-Computador , Terapia Combinada , Terapia por Estimulação Elétrica , Humanos , Locomoção/fisiologia , Terapia com Luz de Baixa Intensidade , Córtex Motor/fisiopatologia , Regeneração Nervosa , Crescimento Neuronal , Fármacos Neuroprotetores/uso terapêutico , Fotoquimioterapia , Qualidade de Vida , Recuperação de Função Fisiológica , Riluzol/uso terapêutico , Medula Espinal/fisiopatologia , Doenças da Medula Espinal/reabilitação , Traumatismos da Medula Espinal/terapia , Transplante de Células-Tronco , Estimulação Transcraniana por Corrente Contínua , Estimulação Elétrica Nervosa Transcutânea
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...