Systemic immune-inflammation index as a predictor of early stroke progression/recurrence in acute atherosclerotic ischemic stroke.

OBJECTIVES: Although the systemic immune-inflammatory index (SII) has recently been correlated with stroke severity and functional outcome, the underlying pathogenesis remains largely unknown. The objective of this study was to explore whether SII could predict early neurologic deterioration (END) in different etiologies of acute ischemic stroke. MATERIALS AND METHODS: From January 2019 to December 2021, a total of 697 consecutive patients with acute ischemic stroke, admitted within 72 hours from stroke onset, were prospectively enrolled. The patients were categorized into 4 groups based on quartiles of SII, calculated as platelets multiplied by neutrophils divided by lymphocytes. END and stroke progression/recurrence were assessed during the first 7 days after stroke onset using predetermined definitions. Logistic regression analysis was conducted to evaluate the association between SII and END, while considering the variation in association across stroke etiologies. RESULTS: END occurred in 135 patients: 24 (3.4%) for Group I, 25 (3.6%) for Group II, 33 (4.7%) for Group III, and 53 (7.6%) for Group IV. Among the END subtypes, stroke progression/recurrence stroke was the most prevalent. In the logistic regression model, the adjusted odds ratios (ORs) of END and stroke progression/recurrence for group IV were 2.51 (95% CI, 1.27-4.95) and 1.98 (95% CI, 1.03-3.89), respectively. Among the stroke etiologies, group IV showed a significant increase in END (OR 4.24; 95% CI, 1.42-12.64) and stroke progression/recurrence (OR 4.13; 95% CI, 1.39-12.27) specifically in case of large artery atherosclerosis. CONCLUSIONS: SII independently predicts early stroke progression/recurrence in patients with acute atherosclerotic ischemic stroke.

The simplification of the insomnia severity index and epworth sleepiness scale using machine learning models.

Insomnia and excessive daytime sleepiness (EDS) are the most common complaints in sleep clinics, and the cost of healthcare services associated with them have also increased significantly. Though the brief questionnaires such as the Insomnia Severity Index (ISI) and Epworth Sleepiness Scale (ESS) can be useful to assess insomnia and EDS, there are some limitations to apply for large numbers of patients. As the researches using the Internet of Things technology become more common, the need for the simplification of sleep questionnaires has been also growing. We aimed to simplify ISI and ESS using machine learning algorithms and deep neural networks with attention models. The medical records of 1,241 patients who examined polysomnography for insomnia or EDS were analyzed. All patients are classified into five groups according to the severity of insomnia and EDS. To develop the model, six machine learning algorithms were firstly applied. After going through normalization, the process with the CNN+ Attention model was applied. We classified a group with an accuracy of 93% even with only the results of 6 items (ISI1a, ISI1b, ISI3, ISI5, ESS4, ESS7). We simplified the sleep questionnaires with maintaining high accuracy by using machine learning models.

Advances in Intraoperative Neurophysiology During Microvascular Decompression Surgery for Hemifacial Spasm.

Microvascular decompression (MVD) is a widely used surgical intervention to relieve the abnormal compression of a facial nerve caused by an artery or vein that results in hemifacial spasm (HFS). Various intraoperative neurophysiologic monitoring (ION) and mapping methodologies have been used since the 1980s, including brainstem auditory evoked potentials, lateral-spread responses, Z-L responses, facial corticobulbar motor evoked potentials, and blink reflexes. These methods have been applied to detect neuronal damage, to optimize the successful decompression of a facial nerve, to predict clinical outcomes, and to identify changes in the excitability of a facial nerve and its nucleus during MVD. This has resulted in multiple studies continuously investigating the clinical application of ION during MVD in patients with HFS. In this study we aimed to review the specific advances in methodologies and clinical research related to ION techniques used in MVD surgery for HFS over the last decade. These advances have enabled clinicians to improve the efficacy and surgical outcomes of MVD, and they provide deeper insight into the pathophysiology of the disease.

Involvement of the vertebral artery in hemifacial spasm: clinical features and surgical strategy.

The vertebral artery (VA)-involved hemifacial spasm (HFS) has distinctive clinical features and performing microvascular decompression (MVD) is challenging. We described the clinical presentations of VA-involved HFS and the outcomes of MVD using the interposition method. Between January 2008 and March 2015, MVD was performed in 271 patients with VA-involved HFS. Demographic characteristics, preoperative severity, intraoperative findings, spasm-free outcome, and complications were retrospectively evaluated. A control group of 1500 consecutive patients with non-VA-involved HFS was enrolled. VA-involved HFS was associated with older age (p < 0.001), less female predominance (p < 0.001), more left-sided predominance (p < 0.001), and rapid symptom progression before MVD (p < 0.001). The Teflon Fulcrum method allowed intraoperative identification of the neurovascular compression site in 92.6% of the cases, and showed more severe indentation on the facial nerve (p < 0.001). Changes in the brainstem auditory evoked potentials during MVD (p < 0.001) and postoperative non-serviceable hearing loss (p < 0.001) were more frequent in patients with VA-involved than in non-VA-involved HFS. The spasm-free outcome and overall complication rates after MVD were not significantly different between the groups. VA-involved HFS has distinctive clinical features and poses a major surgical challenge for MVD success. The interposition method is a feasible surgical strategy in VA-involved HFS.

A prewarning sign for hearing loss by brainstem auditory evoked potentials during microvascular decompression surgery for hemifacial spasm.

OBJECTIVE: We aimed to define the prewarning sign of brainstem auditory evoked potentials (BAEPs) associated with cerebellar retraction (CR) during microvascular decompression surgery for hemifacial spasm. METHODS: A total of 241 patients with a latency prolongation of 1 ms or an amplitude decrement of 50% of wave V were analyzed. According to BAEPs before significant changes during CR, patients were classified into Groups A (latency prolongation of wave I [≥0.5 ms] without prolongation of the I-III interpeak interval [<0.5 ms]) and B (no latency prolongation of wave I [<0.5 ms] with prolongation of the I-III interpeak interval [≥0.5 ms]). BAEPs and postoperative hearing loss (HL) were compared between the two groups. RESULTS: Group B comprised 160 (66.4%) patients. With maximal changes in wave V, latency prolongation (≥1 ms) with amplitude decrement (≥50%) was more common in Group B (p < 0.018). At the end of the operation, wave V loss was observed in 11 patients, including 10 patients from Group B. Five patients developed postoperative HL; all were from Group B. CONCLUSIONS: Latency prolongation of wave III during CR was associated with serious BAEPs changes and postoperative HL. SIGNIFICANCE: Latency prolongation of wave III is a significant prewarning sign.

Recent glycemic control can predict the progressive motor deficits of acute subcortical infarction with diabetes or prediabetes.

BACKGROUND AND PURPOSE: The predictors of progressive motor deficits in acute subcortical infarctions are still controversial. It is not known whether glycemic control influences on stroke progression. METHODS: A total of 268 consecutive patients with diabetes or prediabetes who had acute (< 24 h) subcortical infarction were enrolled. (1) All patients were divided into 4 groups by quartile of glycated hemoglobin (HbA1c). (2) Only the patients with diabetes were divided by effective glycemic control. Progressive motor deficits were prospectively captured and defined as an increase of motor score ≥ 1 on the upper or lower limb items of the National Institute of Health Stroke Scale within 72 h from stroke onset. RESULTS: Progressive motor deficits occur in 8/78 (10.3%) for ≤ 5.9, 15/61 (24.6%) for 6.0-6.4, 16/62 (25.8%) for 6.5-7.4, and 30/67 (44.8%) for ≥ 7.5. In diabetic patients alone, those occur in 5/37 (13.5%) for ≤ 6.5, 10/42 (23.8%) for 6.6-7.0, 12/42 (28.6%) for 7.1-8.0, and 24/50 (48.0%) for ≥ 8.1. An adjusted OR of progressive motor deficits was 2.61 (95% confidence interval [CI] 0.98-7.00, P = .056) for 6.0-6.4, 3.42 (95% CI 1.27-9.18, P = .015) for 6.5-7.4, and 6.65 (95% CI 2.38-18.62, P < .001) for ≥ 7.5. In diabetic patients alone, those were 3.15 (95% CI 0.89-11.15, P = .075) for 6.6-7.0, 2.90 (95% CI 0.79-10.61, P = .107) for 7.1-8.0, and 4.17 (95% CI 1.07-16.25, P = .038) for ≥ 8.1. The optimal cutoff value of HbA1c was 6.65% in discriminating progressive motor deficits. CONCLUSION: Increased HbA1c was associated with higher incidence of progressive motor deficits in acute subcortical infarction with diabetes and prediabetes.

Dizziness in patients with early stages of Parkinson's disease: Prevalence, clinical characteristics and implications.

AIM: The clinical features and implications of dizziness in patients with Parkinson's disease (PD) remain little known. This study aimed to investigate the clinical characteristics of dizziness, and the association of dizziness with motor and non-motor symptoms in early stages of PD. METHODS: Demographics and clinical characteristics of patients with early PD (disease duration ≤5 years) were retrospectively assessed. The characteristics of dizziness were surveyed in each parkinsonian patient according to existence, frequency, duration and nature. Not only motor symptoms, but also non-motor scales for global cognition, anxiety, depression and fatigue were evaluated to identify risk factors of dizziness. RESULTS: Of a total of 80 patients with early PD, 37 (46.3%) had dizziness. The characteristics of dizziness included short duration (seconds to minutes) and frequent occurrence (several times in a day or a week). The most common type of dizziness was orthostatic (40.5%), followed by non-specific and disequilibrium type. Among many scales for motor and non-motor symptoms, dizzy patients with early PD showed lower scores of Montreal Cognitive representing global cognition than non-dizzy people. A lower Montreal Cognitive Assessment score was the only factor significantly related to dizziness in patients with early PD. CONCLUSIONS: We found that dizziness frequently occurs in early parkinsonian patients. It is highly linked to low Montreal Cognitive Assessment scores in patients with early PD, inferring that dizziness might be a potential non-motor symptom associated with cognitive decline in PD. Geriatr Gerontol Int 2020; 20: 443-447.

Significance of wave I loss of brainstem auditory evoked potentials during microvascular decompression surgery for hemifacial spasm.

OBJECTIVE: We sought to define the significance of wave I loss of brainstem auditory evoked potentials (BAEPs) during microvascular decompression (MVD) surgery for hemifacial spasm. METHODS: Out of 670 patients, 36 showed wave V loss during MVD surgery. These patients were classified into the following two groups based on wave I loss: Total wave loss, including wave I loss, and wave V loss with persistent wave I. We analyzed the differences in postoperative complications between the groups. We also investigated when wave I loss occurred during MVD surgery. RESULTS: Of the 36 patients, 24 (66.7%) exhibited wave I persistence and 12 (33.3%) exhibited total wave loss. The patients who showed total wave loss were significantly more likely to exhibit postoperative hearing loss (p = 0.009). In addition, these patients exhibited a significantly higher frequency of postoperative complications such as dizziness and tinnitus (p = 0.002 and p = 0.031, respectively). Total wave loss occurred more frequently after the decompressive procedure of MVD surgery. CONCLUSIONS: Total wave loss, including wave I loss, was more closely associated with severe postoperative complications. Total wave loss occurred more frequently after the decompressive procedure of MVD surgery. SIGNIFICANCE: These findings suggest the significance of wave I loss of BAEPs.

Intraoperative Neurophysiological Monitoring during Microvascular Decompression Surgery for Hemifacial Spasm.

Hemifacial spasm (HFS) is due to the vascular compression of the facial nerve at its root exit zone (REZ). Microvascular decompression (MVD) of the facial nerve near the REZ is an effective treatment for HFS. In MVD for HFS, intraoperative neurophysiological monitoring (INM) has two purposes. The first purpose is to prevent injury to neural structures such as the vestibulocochlear nerve and facial nerve during MVD surgery, which is possible through INM of brainstem auditory evoked potential and facial nerve electromyography (EMG). The second purpose is the unique feature of MVD for HFS, which is to assess and optimize the effectiveness of the vascular decompression. The purpose is achieved mainly through monitoring of abnormal facial nerve EMG that is called as lateral spread response (LSR) and is also partially possible through Z-L response, facial F-wave, and facial motor evoked potentials. Based on the information regarding INM mentioned above, MVD for HFS can be considered as a more safe and effective treatment.

Missed Culprits in Failed Microvascular Decompression Surgery for Hemifacial Spasm and Clinical Outcomes of Redo Surgery.

OBJECTIVE: To identify causes of recurrent hemifacial spasm (HFS) after initial microvascular decompression (MVD) and to assess the feasibility of redo MVD. METHODS: The study included 21 patients who underwent redo MVD over the last 2 decades. Their medical charts were retrospectively reviewed for preoperative medical history, previous and redo MVD intraoperative findings, and previous and redo MVD postoperative outcomes. RESULTS: Redo MVDs were the second operation in 20 patients and the third operation in 1 patient. The median interval between previous and redo MVD was 46.3 months (range, 14.4-188.2 months). Compression of offending vessels such as a vein or perforating artery located medial to or at the cisternal segment of the facial nerve was found to be a possible cause of previous MVD failure. MVD failure resulted from neglect of offending vessels in 10 patients, insufficient decompression in 7 patients, and untouched neurovascular compression sites in 4 patients. Spasm-free rates after redo MVD were 80.5% at 1 year and 90.5% in the last year of follow-up (median, 15.8 months; range, 3.6-152.0 months). Permanent hearing loss and facial palsy were each observed in 2 patients (9.5%). In addition, 1 patient each experienced cerebellar infarction and vocal cord palsy. CONCLUSIONS: Redo MVD remains a feasible treatment option for patients with HFS who failed to benefit from previous MVD, but it is associated with an increased risk of cranial nerve and vascular injuries.

Vascular Complications in Microvascular Decompression: A Survey of 4000 Operations.

BACKGROUND: Vascular complications in posterior fossa surgery, even in microvascular decompression (MVD) involving a small cranial opening, can have catastrophic consequences. We analyzed these complications to determine the incidence, risk factors, prognosis, and preventive measures involved. METHODS: Between April 1997 and March 2018, 4000 consecutive patients with neurovascular compression syndrome were admitted and underwent MVD. We reviewed the medical records of patients who developed vascular complications after MVD, focusing on their past medical history, perioperative laboratory findings and images, surgical findings, and postoperative progress. RESULTS: Vascular complications developed in 28 patients (0.7%), including 24 with hemifacial spasm and 4 with trigeminal neuralgia. Twenty-two hemorrhagic (78.6%) and 6 ischemic (21.4%) complications occurred, with epidural hematoma the most frequent type identified. Ten patients (35.7%) patients were asymptomatic and 18 (64.3%) were symptomatic. Six patients (21.4%) underwent revision surgery, such as hematoma removal, craniectomy, or extraventricular drainage insertion. At the last follow-up, dizziness was the most commonly reported sequela from vascular complications. No deaths had occurred. CONCLUSIONS: Vascular complications are rare, but can be the most devastating adverse outcome of MVD surgery. Unusual signs and symptoms after MVD should prompt special attention to early management and patient safety.

Seizure-like activities in patients with head-up tilt test-induced syncope.

The purpose of this study was to assess the prevalence and the characteristics of seizure-like activities during head-up tilt test (HUT)-induced syncope, in patients with suspected vasovagal syncope (VVS). We also evaluated the differences in hemodynamic parameters between patients with and without seizure-like activities.A total of 71 patients with suspected VVS, who showed syncope during HUT between October 2010 and May 2013, were analyzed. Electrocardiogram and hemodynamic parameters were continuously monitored during HUT. We also performed video recording of patients during HUT to identify eyeball deviation or seizure-like limb movements.In all, 47 patients (66.2%) showed seizure-like activities at the time of syncope during HUT, 14 patients presented eyeball deviation, without abnormal limb movements, and 33 patients showed abnormal limb movements, such as myoclonic or tonic-clonic activities, as well as eyeball deviation. Upon comparison of the 2 groups with or without seizure-like activities, patients showing seizure-like activities presented a significantly lower heart rate at the time of syncope in HUT (38.51 ±â€Š16.81 vs 49.67 ±â€Š20.12, P < .05). Also, upon comparison within patients showing seizure-like activities, the patients who showed abnormal limb movements with eyeball deviation demonstrated a significantly lower systolic blood pressure and cardiac output at the time of syncope (34.30 ±â€Š12.24 vs 49.00 ±â€Š14.14, P < .05; 0.58 ±â€Š0.40 vs 1.32 ±â€Š0.97, P < .05).Seizure-like activities were observed in high percentage in about 66% of patients during HUT-induced syncope. The occurrence of seizure-like activities was associated with more severe transient hemodynamic changes, such as lower heart rate, systolic blood pressure, and cardiac output at the time of the HUT-induced syncope.

A new method for monitoring abnormal muscle response in hemifacial spasm: A prospective study.

OBJECTIVE: To examine a new abnormal muscle response (AMR) monitoring method during microvascular decompression (MVD) for hemifacial spasm. METHODS: 486 patients with hemifacial spasm were monitored for an AMR during MVD with a new method involving preoperative mapping and intraoperative centrifugal stimulation of the facial nerve. For the last 62 patients, we performed the AMR monitoring using both, the new and conventional methods simultaneously. RESULTS: Preoperative facial nerve mapping showed that the maximal AMR was detected most frequently (66.9%) at the "F" location (the direction towards the frontalis muscle). An intraoperative AMR was observed in 86.2% of the patients, which disappeared after MVD in 96.4% of the patients. A comparison of the new and conventional methods respectively showed that AMR disappearance after MVD was observed in 98.2% and 61.8% of the patients, no AMR in 0% and 9.1%, and persistent AMR after MVD in 1.8% and 29.1%. CONCLUSIONS: The new AMR monitoring method demonstrated greater AMR monitoring efficacy and supports the finding that disappearance of an AMR is a good indicator of effective decompression during MVD surgery. SIGNIFICANCE: Preoperative mapping and intraoperative centrifugal stimulation of the facial nerve during MVD surgery in HFS patients showed greater efficacy of AMR monitoring.

A surgical strategy to prevent delayed epidural hematoma after posterior fossa surgery using lateral suboccipital retrosigmoid approach.

Although non-traumatic postoperative delayed epidural hematoma (EDH) after posterior fossa surgery is rare, measures to prevent it need to be pursued due to its catastrophic results. In this report, we describe a surgical strategy to prevent delayed EDH after posterior fossa surgery. Key dural tacking sutures were performed at the medial and cephalic margin of the dura. We have performed key dural tacking sutures on 454 patients with neurovascular compression syndrome during microvascular decompression surgeries since April 2016, and no hemorrhagic complication, including delayed EDH, occurred. We discovered that key dural tacking sutures can be helpful in preventing postoperative posterior fossa delayed EDH.

The critical warning sign of real-time brainstem auditory evoked potentials during microvascular decompression for hemifacial spasm.

OBJECTIVE: The aim of this study was to define the critical warning sign of real-time brainstem auditory evoked potential (BAEP) for predicting hearing loss (HL) after microvascular decompression (MVD) for hemifacial spasm (HFS). METHODS: Nine hundred and thirty-two patients with HFS who underwent MVD with intraoperative monitoring (IOM) of BAEP were analyzed. We used a 43.9 Hz/s stimulation rate and 400 averaging trials to obtain BAEP. To evaluate HL, pure-tone audiometry and speech discrimination scoring were performed before and one week after surgery. We analyzed the incidence for postoperative HL according to BAEP changes and calculated the diagnostic accuracy of significant warning criteria. RESULTS: Only 11 (1.2%) patients experienced postoperative HL. The group showing permanent loss of wave V showed the largest percentage of postoperative HL (p < 0.001). No patient who experienced only latency prolongation (≥1 ms) had postoperative HL. Loss of wave V and latency prolongation (≥1 ms) with amplitude decrement (≥50%) were highly associated with postoperative HL. CONCLUSIONS: Loss of wave V and latency prolongation of 1 ms with amplitude decrement ≥50% were the critical warning signs of BAEP for predicting postoperative HL. SIGNIFICANCE: These findings elucidate the critical warning sign of real-time BAEP.

The pathogenesis of delayed epidural hematoma after posterior fossa surgery.

The purpose of this study was to analyze the pathogenesis of delayed epidural hematoma (EDH) after posterior fossa surgery. Non-traumatic, non-arterial origin delayed EDH after posterior fossa surgery is extremely rare. Moreover, the pathogenesis of its supratentorial extension is obscure. Between April 1997 and June 2016, over 3300 patients underwent microvascular decompression (MVD) for neurovascular compression syndrome. The medical chart of four patients with delayed EDH were retrospectively reviewed. The median time from MVD to re-CT scan was 58 h (range, 33-100). All patients underwent hematoma evacuations. Intraoperative findings during hematoma evacuation revealed only an oozing hemorrhage from the transverse sinus with no definitive bleeding focus. The patients spent a median of 21.5 days (range, 11-39) at the hospital. At the last follow-up, all patients had fully recovered without significant neurological deficits and exhibited complete relief or minimal symptoms from hemifacial spasm (HFS). Postoperative uncontrolled bleeding from the dural venous sinus can sometimes cause an insidious-onset or delayed posterior fossa EDH.

Ultrasonographic and Electrophysiological Evaluation of Ulnar Nerve Instability and Snapping of the Triceps Medial Head in Healthy Subjects.

OBJECTIVE: To evaluate the relationship between ulnar nerve instability and snapping of the triceps medial head during elbow flexion. DESIGNS: Twenty-six healthy individuals were recruited. The primary outcome measures were ultrasonographic and electrophysiological parameters of the ulnar nerve. Ulnar nerve instability was classified into three types based on the degree of ulnar nerve movement: no dislocation (Type N), subluxation (Type S), and dislocation (Type D). RESULTS: In the elbow 90-degree position, the incidences of Type N, S, and D were 41 (78.8%), 8 (15.4%), and 3 (5.8%) elbows, respectively; in the full flexion position, the incidences of Types N, S, and D were 24 (46.2%), 19 (36.5%), and 9 (17.3%) elbows, respectively. Spearman's correlation coefficients between ulnar nerve instability and snapping of the triceps medial head in the elbow 90-degree and full flexion positions were 0.808 and 0.889 (P < 0.001), respectively. The ulnar sensory response in Type S was of prolonged latency and decreased amplitude compared with that in Type N or D in the elbow full flexion position. CONCLUSIONS: Ulnar nerve instability increased with elbow flexion and correlated with snapping of the triceps medial head. Ultrasonography of the ulnar nerve is an important tool in ulnar nerve instability assessment.