Correlation between time to diagnosis and rehabilitation outcomes in patients with spinal dural arteriovenous fistula.

BACKGROUND: Spinal dural arteriovenous fistulas (SDAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy although they are under diagnosed. Surgical or embolization treatment of SDAVFs improved significantly in the last decade. However, a high percentage of patients are still left with severe disability. OBJECTIVE: To describe the correlation between time to diagnosis and the rehabilitation outcomes of eight patients with SDAVFs. DESIGN: Retrospective chart study of all SDAVF patients in 20 years. SETTING: A tertiary university rehabilitation center. MAIN OUTCOME MEASURES: The lower extremities motor score (LEMS), Functional Independence Measure (FIM), Spinal Cord Independence Measure (SCIM) and Walking Scale for Spinal Cord Injury (WISC II). Overall prognosis was evaluated using the Aminoff-Logue scale (ALS). RESULTS: There were seven men and one woman with mean age of 61.3 ± 15 (30-72) and mean time until the diagnosis of SDAVF of 265.5 ± 245 days (4-730). At the end of rehabilitation period, five of the eight patients remained wheelchair dependent. Strong correlation was found between LEMS, FIM, SCIM, and WISC II scores and the functional level according to the ALS scale. A significant correlation was found between time to diagnosis and the height of the SDAVF, the clinical and rehabilitation outcomes. Patients with high SDAVF which were diagnosed late had the poorest prognosis. CONCLUSIONS: The potential for functional ambulation in patients with SDAVF is related to the time of intervention. This finding emphasizes the important of early diagnosis and early intervention in SDAVF.

Lack of migraine in headaches of familial dysautonomia patients.

Familial Dysautonomia (FD) is an autosomal recessive genetic disease where autonomic and sensory functions are defective affecting many body systems including the vascular. Plasma level of the neurotransmitter Calcitonin Gene Related Peptide (CGRP) is decreased in FD patients. This compound has been implicated to take part in the pathogenesis of migraine. We aimed to evaluate the symptoms of headaches in FD patients and to test the hypothesis that these patients will have a low incidence of migrainous headache. Sixty-five FD patients were evaluated by a medical headache questionnaire. Mean age was 23.73 + 10.82 years (mean 21 years) and there were 37 males (57 %).Thirty-eight patients (58.5 %) described having episodic headache conforming to criteria of tension headache, and in 17 of those 38 (44.7 %) headache were dependent on changes in blood pressure, except from one patient who had complaints that matched diagnosis of acephalic migraine. None of the patients had symptoms compatible with migraine or cluster headache. Results show that the headache is a very common complaint in FD, there is lack of migraine symptoms in this group. This might be attributed to defective sensory innervation and deficiency of CGRP. FD could be regarded as a human model for CGRP deficiency when studying the pathogenesis of migraine.

Rehabilitation outcomes of stroke patients treated with tissue plasminogen activator.

OBJECTIVE: To investigate the influence of thrombolysis on functional outcomes after rehabilitation. BACKGROUND: Systemic thrombolysis with tissue plasminogen activator (tPA) is considered the mainstay of acute stroke therapy and was found to improve short-term outcome. DESIGN: Matched case-controlled design. SETTING: Inpatient neurology and rehabilitation departments. PARTICIPANTS: Thirty-seven patients given tPA and 37 control patients not treated with lytics because of protocol limits. METHODS: We retrospectively analyzed data from a cohort of stroke patients who were treated with systemic tPA. The rehabilitation outcome of thrombolysis-treated patients was compared with that observed for tPA-ineligible and age- and stroke severity-matched patients treated at the same neurology and rehabilitation departments. MAIN OUTCOME MEASURE: Neurological evaluation was assessed with the National Institutes of Health stroke scale (NIHSS). Activity of daily living was measured using the Functional Independence Measure (FIM) instrument. Functional outcome was measured using the modified Rankin scale (mRS). RESULTS: The treatment group included 37 patients given tPA; 37 tPA-ineligible patients served as controls. On admission to rehabilitation, there were no significant differences in functional, neurological, and rehabilitation parameters between the groups. At the end of the rehabilitation period, NIHSS scores were significantly lower in the thrombolysis group (P = .036). More patients in the thrombolysis group reached functional independence defined as mRS < or =2 (20/37 versus 10/37; P = .03). At the end of rehabilitation, total FIM score (mean 102.8 versus 93.9; P = .039), total FIM gain (mean 27.8 versus 21.4; P = .09), and total FIM efficiency scores (0.8 versus 0.43; P = .013) were higher in the thrombolysis group and more patients in this group were discharged home. CONCLUSIONS: Although the bulk of neurological improvement occurred before the inpatient rehabilitation, thrombolysis-treated patients continue to improve faster and to a larger extent during the rehabilitation period suggesting that the beneficial effects of thrombolysis continue beyond the acute phase.