Presentation outside office hours does not negatively influence treatment times for reperfusion therapy for acute ischemic stroke.

BACKGROUND: Treatment outside office hours has been associated with increased workflow times for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). Limited data suggest that this "off-hours effect" also exists for endovascular treatment (EVT). We investigated this phenomenon in a well-organized acute stroke care region in the Netherlands. METHODS: Retrospective, observational cohort study of consecutive patients with AIS who received reperfusion therapy in the Greater Amsterdam Area, consisting of 14 primary stroke centers and 1 comprehensive stroke center (IVT: 2009-2015, EVT: 2014-2017). Office hours were defined as presentation during weekdays between 8 AM and 5 PM, excluding National Festive days. Primary outcome was door-to-treatment time (door-to-needle [DNT] for IVT, door-to-groin [DGT] for EVT). For DGT, we used the door time of the first hospital. Other outcomes were in-hospital mortality, modified Rankin Scale (mRS) score at 90 days and symptomatic intracranial hemorrhage (sICH). We performed multivariable linear and logistic regression analyses and used multiple imputation to account for missing values. RESULTS: In total, 59% (2450/4161) and 61% (239/395) of patients treated with IVT and EVT, respectively, presented outside office hours. Median DNT was minimally longer outside office hours (32 vs. 30 min, p = 0.024, adjusted difference 2.5 min, 95% CI 0.7-4.2). Presentation outside office hours was not associated with a longer DGT (median 130 min for both groups, adjusted difference 7.0 min, 95% CI - 4.2 to 18.1). Clinical outcome and sICH rate also did not differ. CONCLUSION: Presentation outside office hours did not lead to clinically relevant treatment delays for reperfusion therapy in patients with AIS.

[Sensory disturbances caused by multivitamin preparations]. / Gevoelsstoornissen veroorzaakt door multivitaminepreparaten.

2 patients, men aged 60 and 65 years, presented with symptoms of chronic sensory polyneuropathy. Symptoms in the first patient were bilateral numbness in the hands and leg pain and, in the second patient, painful tingling in the legs. Pyridoxine (vitamin B6) toxicity due to daily use of multivitamin supplements was diagnosed. The patients were taking 24 and 40 mg per day, respectively. Neurotoxic syndromes due to pyridoxine overdose have been described before in patients taking high-dose vitamin B. These patients mostly developed progressive sersory neuronopathy with sensory ataxia. Chronic sensory polyneuropathy has not been associated with the use of vitamin supplements, which have previously been considered harmless. Both patients recovered after discontinuation of supplement intake.

Olfactory function after mild traumatic brain injury.

OBJECTIVE: The aim of this study was to determine the incidence of olfactory dysfunction after mild traumatic brain injury (MTBI). Damage to the olfactory bulbs or frontal cortex has been reported in MTBI, but olfactory dysfunction after MTBI has not been studied in a prospective way before. DESIGN: Patients with first-time MTBI were included. Patients' olfactory threshold values (Hyposmia Utility Kit by Olfacto-Labs) were measured 2 weeks after the trauma. Associations between olfactory threshold values and individual symptoms and S-100B and NSE concentrations were examined, using multiple linear regression analysis, adjusting for the influence of age. RESULTS: Twenty-two per cent of 111 included patients had hyposmia and 4% had anosmia. Thresholds at 2 weeks showed no significant associations with the presence of symptoms at the ER, nor with early concentrations of S-100B or NSE. CONCLUSIONS: Although a high prevalence of olfactory dysfunction was found, no correlation was found between olfactory dysfunction and acute parameters of MTBI.

Prediction of post-traumatic complaints after mild traumatic brain injury: early symptoms and biochemical markers.

OBJECTIVES: To identify parameters at first presentation after mild traumatic brain injury (MTBI) that are predictive of the severity of post-traumatic complaints (PTC) after six months. Early recognition of patients with MTBI who are at risk of developing PTC would be useful because early follow up at the outpatient clinic may help to reduce the severity of these complaints in the long run. METHODS: The presence of symptoms in the emergency room (ER) (headache, dizziness, nausea, vomiting, and neck pain) and biochemical markers (neurone specific enolase and S-100B) in serum were assessed as possible predictive variables for the severity of PTC. Outcome variables were the severity of 16 PTC six months after the trauma. RESULT: After six months, the severity of most complaints had declined to pretrauma levels but medians for headache, dizziness, and drowsiness were still increased. In a series of 79 patients, 22 (28%) reported one or more PTC after six months. After adjustment for baseline variables, an at least twofold increased severity of all PTC subgroups was reported by those patients reporting headache, dizziness, or nausea in the ER. A twofold increased severity of "cognitive" and "vegetative" PTC was also found in those with increased concentrations of biochemical serum markers at first presentation. The prevalence of full recovery after six months increased from 50% in patients with three symptoms to 78% in those with no symptoms in the ER. Inclusion of biochemical markers showed that all 10 patients with no symptoms in the ER and normal markers recovered fully. CONCLUSIONS: The presence of headache, dizziness, or nausea in the ER after MTBI is strongly associated with the severity of most PTC after six months. Identifying MTBI patients in the ER without headache, dizziness, nausea, or increased serum marker concentrations may be a promising strategy for predicting a good outcome.

Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest.

BACKGROUND: Outcome after mild traumatic brain injury (MTBI) is determined largely by the appearance of post-traumatic complaints (PTC). The prevalence of PTC after six months is estimated to be between 20 and 80%. Bed rest has been advocated to prevent PTC but its effectiveness has never been established. OBJECTIVE: To evaluate the effect of bed rest on the severity of PTC after MTBI. METHODS: Patients presenting with MTBI to the emergency room were randomly assigned to two intervention strategies. One group was advised not to take bed rest (NO) and the other to take full bed rest (FULL) for six days after the trauma. The primary outcome measures were severity of PTC on a visual analogue scale and physical and mental health on the medical outcomes study 36 item short form health survey (SF-36) at two weeks and three and six months after the trauma. RESULTS: Between October 1996 and July 1999, 107 (54 NO, 53 FULL) patients were enrolled. Outcome variables in both groups clearly improved between two weeks and six months. After adjustment for differences in baseline variables, most PTC tended to be somewhat more severe in the FULL group six months after the trauma, but no significant differences were found. Neither were there any significant differences in the outcome parameters between the two groups after three months. Two weeks after the trauma, most PTC in the FULL group were slightly less severe than those in the NO group, and physical subscores of the SF-36 in the FULL group were slightly better. These differences were not significant. Patients in the FULL group reported significantly less dizziness during the intervention period. CONCLUSIONS: As a means of speeding up recovery of patients with PTC after MTBI, bed rest is no more effective than no bed rest at all. Bed rest probably has some palliative effect within the first two weeks after the trauma.

Diagnostic criteria and differential diagnosis of mild traumatic brain injury.

Brain injury is classified clinically as severe, moderate or mild brain injury characteristics, including admission Glasgow coma score, duration of unconsciousness and post-traumatic amnesia and any focal neurological findings. Most traumatic brain injuries are classified as mild traumatic brain injury (MTBI). Headache, nausea and dizziness are frequent symptoms after MTBI and may continue for weeks to months after the trauma. MTBI may also be complicated by intracranial injuries. Experimental animal models and post-mortem studies have shown axonal damage and dysfunction in MTBI. This damage is mostly localized in the frontal lobes. Serum S-100 and NSE have been reported to be markers for the seventy of brain damage. In the literature, indications for radiodiagnostic evaluation following MTBI have been the subject of debate. Radiographs of the skull are used to exclude skull fractures, but are not useful for an evaluation of brain injury. Computed tomography of the brain seems to be the best way to exclude the development of relevant intracranial lesions. MTBI has a good clinical outcome, although a substantial group of patients develop post-concussional complaints (PCC). There is little information on the effectiveness of various methods suggested for reducing the frequency of PCC.

Management of mild traumatic brain injury: lack of consensus in Europe.

Mild traumatic brain injury (MTBI) accounts for most traumatic brain injuries and is an important cause of morbidity. Recent studies in various European countries have shown that no consensus exists about management of patients with MTBI. This study describes the management of MTBI patients in various European hospitals. A short questionnaire covering the areas of interest was sent to several EFNS members in European countries. The results of the inquiry show that there is, at present, no consensus about criteria for, or management of MTBI in European hospitals.

S-100B and neuron-specific enolase in serum of mild traumatic brain injury patients. A comparison with health controls.

OBJECTIVES: The aim of the study was to determine whether serum concentrations of neuron-specific enolase (NSE) and S100-B in mild traumatic brain injury (MTBI) patients are higher than in serum of healthy controls. MATERIAL AND METHODS: Blood samples from 104 MTBI patients were taken shortly after the trauma for measurement of S-100B and NSE in serum. In 92 healthy persons these markers were also measured. Marker concentrations in serum of patients and controls were compared. In the patient group the relation between serum-marker concentrations and clinical symptoms and signs, that occurred shortly after the traumatic event, were evaluated. RESULTS: Median NSE concentration was only slightly higher in patients (9.8 microg/l; 10 to 90 percentile range 6.9 to 14.3 microg/ l) than in controls (9.4 microg/l; 6.3 to 13.3 microg/l). Median S-100B concentration was significantly higher in patients (0.25 microg/l; 0.00 to 0.68 microg/l) than in controls (0.02 microg/l; 0.00 to 0.13 microg/l). An association was found between S-100B concentrations and vomiting in patients. CONCLUSIONS: S-100B is a useful marker for brain damage in MTBI patients and seems to be associated with the presence of vomiting after the trauma.

MR imaging, single-photon emission CT, and neurocognitive performance after mild traumatic brain injury.

BACKGROUND AND PURPOSE: Mild traumatic brain injury (mTBI) (Glasgow Coma Scale = 14-15) is a common neurologic disorder and a common cause of neurocognitive deficits in the young population. Most patients recover fully from mTBI, but 15% to 29% of patients have persistent neurocognitive problems. Although a partially organic origin is considered likely, little brain imaging evidence exists for this assumption. The aims of the present study were to establish the prevalence of posttraumatic lesions in mTBI patients on MR images and to assess the relation between these imaging findings and posttraumatic symptoms. Secondly, we explored the value of early posttraumatic single-photon emission CT (SPECT) for the evaluation of mTBI. METHODS: Twenty-one consecutive patients were included in the study. Patients underwent MR examination, technetium-99m hexamethylpropylene amine oxime SPECT, and neurocognitive assessment within 5 days after injury. Neurocognitive follow-up was conducted 2 and 6 months after injury, and MR imaging was repeated after 6 months. Lesion size and brain atrophy were measured on the MR studies. RESULTS: Twelve (57%) of 21 patients had abnormal MR findings, and 11 (61%) of 18 had abnormal SPECT findings. Patients with abnormal MR or SPECT findings had brain atrophy at follow-up. The mean neurocognitive performance of all subjects was within normal range. There was no difference in neurocognitive performance between patients with normal and abnormal MR findings. Patients with abnormal MR findings only showed significantly slower reaction times during a reaction-time task. Seven patients had persistent neurocognitive complaints and one patient met the criteria for a postconcussional syndrome. CONCLUSION: Brain lesions are common after mTBI; up to 77% of patients may have abnormal findings either on MR images or SPECT scans, and these lesions may lead to brain atrophy. The association between hypoperfusion seen on acute SPECT and brain atrophy after 6 months suggests the possibility of (secondary) ischemic brain damage. There is only a weak correlation between neuroimaging findings and neurocognitive outcome.

[Incidence of traumatic head or brain injuries in catchment area of Academic Hospital Maastricht in 1997]. / De incidentie van traumatisch schedel- of hersenletsel in het adherentiegebied van het Academisch Ziekenhuis Maastricht in 1997.

OBJECTIVE: To measure the incidence of traumatic head or brain injury in the catchment area of the Academic Hospital Maastricht (AZM), the Netherlands. DESIGN: Retrospective. METHOD: Data were collected about head injury patients who visited the emergency room of the AZM in 1997 by separate forms that were filled out for each patient who came to the emergency room. Data were added from admission records and radiology records. The AZM had a catchment area of approximately 231,000 people. RESULTS: The emergency room was attended by 1933 patients with traumatic head or brain injury. Head trauma without signs of brain injury was diagnosed in 1440 patients (74%) mild brain injury in 467 (24%) and moderate or severe brain injury in 26 (1%). The mean age was 30 years (range: 0-97) and 29% of all patients were below the age of 15. Two-thirds (67%) of patients were male. An X-ray of the skull was performed in 15% of the cases. In 7% of these X-rays a relevant abnormality was found. Eleven per cent of patients were admitted for observation. The incidence rate of traumatic head or brain injury in 1997 was 836/100,000 and the incidence of admission 88/100,000. The causes were a fall (43%), traffic accident (22%), violence (15%), sports injuries (7%), accidents during work (4%), or other/unknown (9%). CONCLUSION: Most patients with head or brain injury had mild injuries (99%, sole head injury or mild brain injury). Compared with other studies, the annual frequency of hospital admissions was low.

Lemierre syndrome and acute mastoiditis.

Lemierre syndrome seldom follows an episode of pharyngotonsillitis. Characteristically, it is comprised of septic thrombosis of the internal jugular vein and bacteremia, leading to lung emboli and metastatic abscess formation. We describe Lemierre syndrome that complicates an acute mastoiditis, with considerations regarding its pathogenesis and management. Despite its sporadic occurrence, awareness of Lemierre syndrome is important, since early recognition reduces both the morbidity and mortality associated with it.

New MRI findings in Creutzfeldt-Jakob disease: high signal in the globus pallidus on T1-weighted images.

We report a 49-year-old woman with Creutzfeldt-Jakob disease (CJD). In addition to typical high-signal lesions on proton-density and T2-weighted images there was high signal in the globus pallidus bilaterally on T1-weighted images. The latter feature has not been described previously and probably due to deposition of prion protein, as found at autopsy.

Spinal cord compression caused by unusual location and extension of ossified ligamenta flava in a Caucasian male. A case report and literature review.

STUDY DESIGN: A case report of a spinal cord compression caused by ossification of the ligamenta flava is presented together with a review of the literature. OBJECTIVE: To present the diagnosis of ossification of the ligamenta flava in a Caucasian man with a proximal thoracic myelopathy. SUMMARY OF BACKGROUND DATA: This case shows that the upper parts of the thoracic spine can be involved in ossification of the ligamenta flava, which never before has been reported in Caucasian individuals. Furthermore, it is advised that computed tomography scanning and magnetic resonance imaging be combined to provide an accurate diagnosis and proper preoperative evaluation of the bony changes, spinal cord, and compression of the spinal cord. METHODS: A patient with a thoracic spinal cord compression caused by ossification of the ligamenta flava was treated surgically and made a good clinical recovery. Imaging studies, surgical findings, and results of histopathologic investigations were analyzed to substantiate the diagnosis. RESULTS: The results of the surgical findings seemed to be in contrast with those of the imaging studies. This contrast was occasioned by the uncommon perioperative finding of a fusion of the completely ossified upper and lower parts of the involved adjacent ligamenta flava. Ossification of the ligamenta flava was diagnosed by histopathologic examination, which revealed endochondral ossification and lamellar bone formation without fragments of ligamenta flava. CONCLUSION: Although rarely reported in whites, ossification of the ligamenta flava should be considered in all patients presenting with a spinal cord compression, even at high thoracic levels. The prognosis after decompressive surgery can be good, especially if intramedullary hyperintensities are absent on preoperatively performed T2-weighted magnetic resonance images.

[No uniformity in radiodiagnosis and advice by Dutch neurologists in patients with minor brain injuries]. / Geen uniformiteit in radiodiagnostiek en adviezen van Nederlandse neurologen bij patiënten met licht hersenletsel.

OBJECTIVE: To determine diagnostic procedures and medical advice in cases of mild head injury in Dutch hospitals. DESIGN: Questionnaire. SETTING: Academic Medical Hospital, Maastricht, the Netherlands. METHOD: A questionnaire was sent to neurologists of 100 different Dutch hospitals. RESULTS: The response was 85%. X-rays of the skull were made by 73% of the respondents, of the cervical spine by 46%. CT scans of the brain were made only on indication. A waking advice for the first 12-24 hours following a mild head injury was given in 95%. Bed rest and work stoppage were prescribed in 37% and 80% respectively. The duration of this bed rest and work stoppage varied from 1 to 14 days and from 2 to 24 days respectively. In 59% pain medication was prescribed and 40% of the patients were seen at least once for a control visit. In 25% of the hospitals a protocol for the treatment of these patients was used, and 52% of the neurologists considered such a protocol desirable. CONCLUSION: This inquiry shows that no consensus exists regarding radiodiagnosis of patients with mild head injury in Dutch hospitals. Apart from the waking advice, the treatment also shows many discrepancies.