NIHSS Scores in Ischemic Small Vessel Disease: A Study in CADASIL

Background: The National Institutes of Health Stroke Scale (NIHSS) is widely used to measure neurological deficits, evaluate the effectiveness of treatment and predict outcome in acute ischemic stroke. It has also been used to measure the residual neurological deficit at the chronic stage after ischemic events. However, the value of NIHSS in ischemic cerebral small vessel disease has not been specifically evaluated. The purpose of this study was to investigate the link between the NIHSS score and clinical severity in a large population of subjects with CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy), a unique model to investigate the pathophysiology and natural history of ischemic small vessel disease. Methods: Demographic and clinical data of 220 patients with one or more lacunar infarcts confirmed by MRI examination and enrolled from a prospective cohort study were analyzed. Detailed neurological examinations, including evaluation of the NIHSS and modified Rankin Scale score (mRS) for evaluating the clinical severity, were performed in all subjects. The sensitivity, specificity, positive and negative predictive values of various NIHSS thresholds to capture the absence of significant disability (mRS = 3, but only 16 (7.3%) had NIHSS >5. All but 1 subject with NIHSS >5 showed mRS >= 3. NIHSS = 3 showed a lower MMSE score than those with mRS = 3 presented either with gait disturbances or MMSE score <25. Conclusions: The present results suggest that the NIHSS cannot reflect the extent of neurological deficit and clinical severity in subjects with lacunar infarctions in the context of a chronic and diffuse small vessel disease. A specific and global neurological scale, including the assessment of cognitive and gait performances, should be developed for ischemic cerebral microangiopathy. Copyright (C) 2012 S. Karger AG, Base

PENGARUH DEPRESI PADA AWAL STROKE (MINGGU I) TERHADAP WAKTU PERBAIKAN DEFISIT NEUROLOGIS PENDERITA STROKE NON HEMORAGIK

Introduction : Depression is the most common type of psychiatric disorder among stroke patients. It is considered as a usual reaction that frequently ignored by family and paramedic. It had been agreed that depression will hampered the neurological deficits recovery of stroke patients. The research was aimed to examine the influence of depression to the recovery time of neurological deficits in infarct stroke patient. Methods : An observation research with prospective study of 70 infarct stroke subjects. The subjects were infact stroke patients hospitalized in B1 neurology ward Dr. Kariadi hospital, January 2005 until December 2005. Neurological deficits were examined with National Institute of Health Stroke Scale (NIHSS) and the depression was diagnosed with Hamilton Depression Rating Scale (HDRS) . Neurological deficits recovery was examine in II, III, IV, V and VI with NIHSS. The patient has recovered if the score of NIHSS is 5 and not recovered if not reach the score of NIHSS 5. The result of the research is shown as graphics and survival analysis tables to know the difference of time recovery. The confounding factor was controlled with logistic regression analysis. The level of significant used this research is with p < 0.05). Results : Subjects without depressed mental state recovered in 3.88 weeks (95% CI 3.37; 4.39) and subjects with depressed mental state recovered in 5.78 weeks (95% CI 5.05; 6.06). Confounding factors that influence to recovery time of improve neurological deficits were age with p = 0.021 and course result of neurological deficit examination at first week with p = 0.001. Conclusions : Stroke patients with depression require more time to recover from neurological deficits compared with non depression stroke patients. Key Words : Post stroke depression – NIHSS – survival analysi

The Efficiency of Glucocorticoid Therapy in Secondary-progressive Course of Multiple Sclerosis

We have investigated the efficacy of pulse-therapy with glucocorticoids (GC) at different time stages (in debuts, at the recurrent stage and at the stage of progression) of secondary progressive course (SPC) of multiple sclerosis (MS) in 70 patients (57 women and 13 men) at the ages from 28 to 67 years (mean age 45±2.5 years). The duration of the disease accounted for 7 up to 34 years (average duration was 19.8±2.3 years). We have conducted 438 courses of GC therapy: at the onsets – 11, at the recurrent stage (RS) – 178 and at the stage of secondary progression-249.The efficacy of hormonal therapy was assessed taking into account the following criteria: the dynamics of regression of neurological symptoms under the influence of the first course of GC therapy at the stage of onsets; a comparative evaluation of remission\u27s duration after admission and without taking GC at the onsets; duration of RS depending on the duration of remissions after the first course of GC therapy; a comparative evaluation of remissions\u27 duration after the 1st (at the stage of onset and/or on the RS), and the period of stabilization on the SPS before the last courses of GC; the variants of secondary progression under the influence of GC courses; scores according the EDSS disability scale after the 1st and before the last course of GC therapy; the rate of progression under the influence of the repeated courses of GC therapy.We have defined the three categories of efficacy at the repeated courses of pulse therapy with GC: the moderate efficacy, the low efficacy, the lack of efficacy. We have not observed the high efficacy in patients with SPC.The patients with MFR &lt;1.0, among which the pulse therapy with GC promoted the prolongation of RS, relieved the severe (less often) and moderate (more often) relapses, the outcome of which was accompanied by a moderate and stable neurologic deficit, were subsumed under the subgroup with moderate efficacy (21 individuals). The most favorable progressive variant of progression prevailed in these patients after transformation of RS into SPS.The patients with different rate of MFR (9 – with MFR &lt;1.0 and 12 – with MFR&gt;1.0), with short (more often) and moderate (less often) RS, during which the accumulation of neurological deficit due to the frequent and heavy relapses had occurred, were subsumed under the subgroup with low efficiency (21 individuals). After transformation into SPS, the recurrent variant of progression prevailed in these patients.The patients who were characterized by short RS, by predominance of severe and prolonged relapses, the MFR value greater than 1.0, the steady accumulation of a pronounced and persistent neurologic deficit, a high rate of progression and high scores on the EDSS disability scale more than 6.5 points) were subsumed under the subgroup with the lack of efficacy (28 individuals). After transformation in the SPC, the most unfavorable variant of progression prevailed (21 patients); significantly less frequent were the recurrent (5 patients) and a combination of a steady and recurrent (2 patients) progression. The persistent lack of efficacy of the hormonal therapy in this subgroup of patients was most likely associated with the genetically determined low individual sensitivity to GC.Therefore, the results of our study showed that the efficacy of GC therapy in SPC of MS is determined by the complex interaction of clinical indicators having the prognostic value, as well as by the number of the genetic factors, which require their further observation

Iatrogenic Spinal Cord Injury Resulting From Cervical Spine Surgery.

STUDY DESIGN: Retrospective cohort study of prospectively collected data. OBJECTIVE: To examine the incidence of iatrogenic spinal cord injury following elective cervical spine surgery. METHODS: A retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network was conducted. Medical records for 17 625 patients who received cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, were reviewed to identify occurrence of iatrogenic spinal cord injury. RESULTS: In total, 3 cases of iatrogenic spinal cord injury following cervical spine surgery were identified. Institutional incidence rates ranged from 0.0% to 0.24%. Of the 3 patients with quadriplegia, one underwent anterior-only surgery with 2-level cervical corpectomy, one underwent anterior surgery with corpectomy in addition to posterior surgery, and one underwent posterior decompression and fusion surgery alone. One patient had complete neurologic recovery, one partially recovered, and one did not recover motor function. CONCLUSION: Iatrogenic spinal cord injury following cervical spine surgery is a rare and devastating adverse event. No standard protocol exists that can guarantee prevention of this complication, and there is a lack of consensus regarding evaluation and treatment when it does occur. Emergent imaging with magnetic resonance imaging or computed tomography myelography to evaluate for compressive etiology or malpositioned instrumentation and avoidance of hypotension should be performed in cases of intraoperative and postoperative spinal cord injury

Diagnostic accuracy of motor evoked potentials to detect neurological deficit during idiopathic scoliosis correction:a systematic review

OBJECTIVE The goal of this study was to evaluate the efficacy of intraoperative transcranial motor evoked potential (TcMEP) monitoring in predicting an impending neurological deficit during corrective spinal surgery for patients with idiopathic scoliosis (IS). METHODS The authors searched the PubMed and Web of Science database for relevant lists of retrieved reports and/or experiments published from January 1950 through October 2014 for studies on TcMEP monitoring use during IS surgery. The primary analysis of this review fit the operating characteristic into a hierarchical summary receiver operating characteristic curve model to determine the efficacy of intraoperative TcMEP-predicted change. RESULTS Twelve studies, with a total of 2102 patients with IS were included. Analysis found an observed incidence of neurological deficits of 1.38% (29/2102) in the sample population. Of the patients who sustained a neurological deficit, 82.8% (24/29) also had irreversible TcMEP change, whereas 17.2% (5/29) did not. The pooled analysis using the bivariate model showed TcMEP change with sensitivity (mean 91% [95% CI 34%-100%]) and specificity (mean 96% [95% CI 92-98%]). The diagnostic odds ratio indicated that it is 250 times more likely to observe significant TcMEP changes in patients who experience a new-onset motor deficit immediately after IS correction surgery (95% CI 11-5767). TcMEP monitoring showed high discriminant ability with an area under the curve of 0.98. CONCLUSIONS A patient with a new neurological deficit resulting from IS surgery was 250 times more likely to have changes in TcMEPs than a patient without new deficit. The authors' findings from 2102 operations in patients with IS show that TcMEP monitoring is a highly sensitive and specific test for detecting new spinal cord injuries in patients undergoing corrective spinal surgery for IS. They could not assess the value of TcMEP monitoring as a therapeutic adjunct owing to the limited data available and their study design

Throat and rectal swabs may have an important role in MRSA screening of critically ill patients.

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) is a major problem in intensive care units (ICU). International guidelines recommend screening patients for MRSA on admission, although consensus on sites required for optimum detection has not been reached. Our aim was to determine whether throat and rectal swabs identified a significant number of additional MRSA-colonised patients not captured by swabbing at keratinized skin carriage sites (anterior nares, perineum and axillae). DESIGN: Prospective cohort study. SETTING: 30-Bed medical and surgical ICU in a tertiary teaching hospital. PATIENTS: One thousand four hundred and eighty adult patients consecutively admitted over 15 months. MEASUREMENTS AND RESULTS: Swabs from carriage sites (anterior nares, perineum, axillae, throat and rectum), wounds and clinical samples taken within 48 h of ICU admission were analysed to identify patients admitted with MRSA. A complete set of carriage swabs were received from 1,470 patients. 105 (7%) patients were admitted with MRSA of which 63 (60%) were detected by a pooled keratinized skin swab (anterior nares, perineum, axillae). A further 36 (34%) patients were detected only by throat or rectal swabs. Indeed, throat and rectal swabs combined had a higher sensitivity than pooled keratinised skin swabs (76 vs. 60% P = 0.0247). Swabs from all carriage sites together detected 95% (100) of MRSA positive patients, with five patients being positive at wound sites only. CONCLUSIONS: The throat and rectum are important and potentially hidden sites of MRSA carriage in critically ill patients. These findings prompt the need for larger studies to determine the most cost-effective screening strategy for MRSA detection. DESCRIPTOR: Non-pulmonary nosocomial infections

A systematic review of neuroprotective strategies after cardiac arrest: from bench to bedside (Part I - Protection via specific pathways).

Neurocognitive deficits are a major source of morbidity in survivors of cardiac arrest. Treatment options that could be implemented either during cardiopulmonary resuscitation or after return of spontaneous circulation to improve these neurological deficits are limited. We conducted a literature review of treatment protocols designed to evaluate neurologic outcome and survival following cardiac arrest with associated global cerebral ischemia. The search was limited to investigational therapies that were utilized to treat global cerebral ischemia associated with cardiac arrest. In this review we discuss potential mechanisms of neurologic protection following cardiac arrest including actions of several medical gases such as xenon, argon, and nitric oxide. The 3 included mechanisms are: 1. Modulation of neuronal cell death; 2. Alteration of oxygen free radicals; and 3. Improving cerebral hemodynamics. Only a few approaches have been evaluated in limited fashion in cardiac arrest patients and results show inconclusive neuroprotective effects. Future research focusing on combined neuroprotective strategies that target multiple pathways are compelling in the setting of global brain ischemia resulting from cardiac arrest

The still under-investigated role of cognitive deficits in PML diagnosis

Background: Despite cognitive deficits frequently represent the first clinical manifestations of Progressive Multifocal Leukoencephalopathy (PML) in Natalizumab-treated MS patients, the importance of cognitive deficits in PML diagnosis is still under-investigated. The aim of the current study is to investigate the cognitive deficits at PML diagnosis in a group of Italian patients with PML. Methods: Thirty-four PML patients were included in the study. The demographic and clinical data, the lesion load and localization, and the longitudinal clinical course was compared between patients with (n = 13) and without (n = 15) cognitive deficit upon PML suspicion (the remaining six patients were asymptomatic). Clinical presentation of cognitive symptoms was described in detail. Result: After symptoms detection, the time to diagnosis resulted to be shorter for patients presenting with cognitive than for patients with non cognitive onset (p = 0.03). Within patients with cognitive onset, six patients were presenting with language and/or reading difficulties (46.15%); five patients with memory difficulties (38.4%); three patients with apraxia (23.1%); two patients with disorientation (15.3%); two patients with neglect (15.3%); one patients with object agnosia (7.7%), one patient with perseveration (7.7%) and one patient with dementia (7.7%). Frontal lesions were less frequent (p = 0.03), whereas temporal lesions were slightly more frequent (p = 0.06) in patients with cognitive deficits. The longitudinal PML course seemed to be more severe in cognitive than in non cognitive patients (F = 2.73, p = 0.03), but differences disappeared (F = 1.24, p = 0.29) when balancing for the incidence of immune reconstitution syndrome and for other treatments for PML (steroids, plasma exchange (PLEX) and other therapies (Mefloquine, Mirtazapine, Maraviroc). Conclusion: Cognitive deficits at PML onset manifest with symptoms which are absolutely rare in MS. Their appearance in MS patients should strongly suggest PML. Clinicians should be sensitive to the importance of formal neuropsychological evaluation, with particular focus on executive function, which are not easily detected without a formal assessment

Cognitive–linguistic deficit and speech intelligibility in chronic progressive multiple sclerosis

Multiple sclerosis (MS) is a disabling neurological disease with varied symptoms, including dysarthria and cognitive and linguistic impairments. Association between dysarthria and cognitive-linguistic deficit has not been explored in clinical MS studies. In MS patients with chronic progressive (CP) MS, the study aimed to investigate the presence and nature of cognitive-linguistic deficit, association between levels of cognitive-linguistic ability and speech intelligibility and of both of these with functional disability and time since onset (TSO) of MS symptoms. The Arizona Battery for Communication Disorders of Dementia (ABCD) (Bayles and Tomoeda 1993), The Assessment of Intelligibility of Dysarthric Speech (AIDS) Sentence Intelligibility Task (Yorkston and Beukelman 1984) and the Modified Barthel Activities of Daily Living Index (MBADLI) (Shah1998) were administered to 24 CP MS participants with dysarthria. 24 non neurologically impaired participants, matched for gender, age and education, formed a control group. For MS participants, linear regression analysis showed a strong association between ABCD and AIDS (Beta = .89, p = 0.005), no association between ABCD and either MBADLI or TSO, a strong association between AIDS and MBADLI (Beta = 0.60, p = .001), and a trend towards association between AIDS and TSO (Beta = -.29, p = 0.08). Correlations between the four included ABCD construct scores and between these and the total ABCD score were significant (r >.60, p .80). The results revealed a strong association between dysarthria, as measured by connected speech intelligibility testing, and cognitive-linguistic deficit, in people with CP type MS. While some of the impairments which are associated with MS, including motor speech disorder, may influence performance on the ABCD, the data support the conclusion that marked cognitive-linguistic deficit is present in CP type MS patients with dysarthria. Deterioration was global, rather than being indicative of a construct specific deficit, and encompassed language, both expression and comprehension. Episodic memory and linguistic expression were especially affected. Speech and language therapists who work with dysarthric patients with CP MS should monitor cognitive-linguistic impairment. Awareness of this may influence assessment, intervention and management, including the information and advice given to patients and their relatives

Autism: A Function of Neurodiversity?

In a culture filled with changes and challenges, there is a need to support groups of people with differences. Neurodiversity is a concept where neurological differences are to be recognized and respected as any other human variation. It is truly a “brain thang”. This “brain thang” means that there are differences in the brain that cause a student to behave, respond, or react differently than a student who appears to function normally. Education should not be compartments in which one has only a mindset of “these are special education students” and “these are not special education students”. The mindset must be changed to “all students” and that they are all “our students”. The information presented in this paper will point to the fact that general education preservice educators need the concept of neurodiversity and its relationship with Autism. These preservice teachers are very likely to have students with special needs in their classrooms. They must be made aware of how to help them be successful. Indeed, oftentimes with minor modifications or adjustments, students with neurological differences can be successful in the general education classroom. It is incumbent upon the general education teacher to be knowledgeable of these strategies and willing to implement them