Pertinence du neuromonitoring multimodal dans les lesions doubles : A propos de la prise en charge, a l’hopital neurologique de lyon, d’une scoliose congenitale avec deficit neurologique rapide

Nous rapportons un cas illustrant qu’une évaluation clinique, radiologique et neurophysiologique exhaustive est obligatoire avant une chirurgie de scoliose sévère. Une patiente a été référée pour bénéficier d’une correction chirurgicale d’une scoliose congénitale malformative. L’examen clinique à l’admission a révélé une tétraparésie qui a imposé un changement urgent de stratégie chirurgicale. L’imagerie par résonance magnétique a objectivé un neurofibrome C2-C3. Les potentiels évoqués somesthésiques (PES) des membres supérieurs et inférieurs étaient normaux mais les potentiels évoqués moteurs (PEM) étaient abolis. Leur réapparition peropératoire lors de la résection du neurofibrome a précédé une amélioration clinique progressive. La récupération spectaculaire des PEM a permis une correction de la déformation de la colonne vertébrale sous surveillance peropératoire plusieurs mois plus tard.   French title: Relevance of multimodal neuromonitoring in dual lesions: About the management, in lyon neurological hospital, of congenital scoliosis with rapid neurological deficit We report a case illustrating that exhaustive clinical, radiological and neurophysiological assessment is mandatory before severe scoliosis surgery. A patient was referred for surgical correction of congenital malformative scoliosis. Clinical examination admission revealed a tetraparesis that enforced an urgent change in surgical strategy. Magnetic Resonance Imaging disclosed a C2-C3 neurofibroma. Upper and lower limbs somatosensory evoked potentials were normal but motor evoked potentials (MEPs) were abolished. Their intra-operative reappearance at the time of neurofibroma resection preceded a progressive clinical improvement. The spectacular MEPs recovery allowed correction of the spinal deformity under intraoperative monitoring several months later

Simple scoring system to predict in-hospital mortality after surgery for infective endocarditis

BACKGROUND: Aspecific scoring systems are used to predict the risk of death postsurgery in patients with infective endocarditis (IE). The purpose of the present study was both to analyze the risk factors for in-hospital death, which complicates surgery for IE, and to create a mortality risk score based on the results of this analysis. METHODS AND RESULTS: Outcomes of 361 consecutive patients (mean age, 59.1\ub115.4 years) who had undergone surgery for IE in 8 European centers of cardiac surgery were recorded prospectively, and a risk factor analysis (multivariable logistic regression) for in-hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver operating characteristic curve analysis. Score validation procedures were carried out. Fifty-six (15.5%) patients died postsurgery. BMI >27 kg/m2 (odds ratio [OR], 1.79; P=0.049), estimated glomerular filtration rate 55 mm Hg (OR, 1.78; P=0.032), and critical state (OR, 2.37; P=0.017) were independent predictors of in-hospital death. A scoring system was devised to predict in-hospital death postsurgery for IE (area under the receiver operating characteristic curve, 0.780; 95% CI, 0.734-0.822). The score performed better than 5 of 6 scoring systems for in-hospital death after cardiac surgery that were considered. CONCLUSIONS: A simple scoring system based on risk factors for in-hospital death was specifically created to predict mortality risk postsurgery in patients with IE

Cortico-cortical and motor evoked potentials to single and paired-pulse stimuli: An exploratory transcranial magnetic and intracranial electric brain stimulation study.

Paired-pulse (PP) paradigms are commonly employed to assess in vivo cortical excitability using transcranial magnetic stimulation (TMS) to stimulate the primary motor cortex and modulate the induced motor evoked potential (MEP). Single-pulse cortical direct electrical stimulation (DES) during intracerebral EEG monitoring allows the investigation of brain connectivity by eliciting cortico-cortical evoked potentials (CCEPs). However, PP paradigm using intracerebral DES has rarely been reported and has never been previously compared with TMS. The work was intended (i) to verify that the well-established modulations of MEPs following PP TMS remain similar using DES in the motor cortex, and (ii) to evaluate if a similar pattern could be observed in distant cortico-cortical connections through modulations of CCEP. Three patients undergoing intracerebral EEG monitoring with electrodes implanted in the central region were studied. Single-pulse DES (1-3 mA, 1 ms, 0.2 Hz) and PP DES using six interstimulus intervals (5, 15, 30, 50, 100, and 200 ms) in the motor cortex with concomitant recording of CCEPs and MEPs in contralateral muscles were performed. Finally, a navigated PP TMS session targeted the intracranial stimulation site to record TMS-induced MEPs in two patients. MEP modulations elicited by PP intracerebral DES proved similar among the three patients and to those obtained by PP TMS. CCEP modulations elicited by PP intracerebral DES usually showed a pattern comparable to that of MEP, although a different pattern could be observed occasionally. PP intracerebral DES seems to involve excitatory and inhibitory mechanisms similar to PP TMS and allows the recording of intracortical inhibition and facilitation modulation on cortico-cortical connections. Hum Brain Mapp 37:3767-3778, 2016. © 2016 Wiley Periodicals, Inc

Diagnostic accuracy of quantitative EEG to detect delayed cerebral ischemia after subarachnoid hemorrhage: A preliminary study

International audienceObjectiveDelayed cerebral ischemia (DCI) is the most important and preventable morbidity cause after subarachnoid hemorrhage (SAH). Therefore, DCI early detection is a major challenge. Yet, neurological examination can be unreliable in poor grade SAH patients. EEG provides information from most superficial cortical area, with ischemia-related changes. This study aims at defining an alpha-theta/delta (AT/D) ratio decrease thresholds to detect DCI. MethodsWe used EEG with a montage matching vascular territories (right and left anterior central and posterior) and compared them to follow-up brain imaging. Results 15 SAH patients (Fischer≥3, World Federation of Neurological Surgeons scale ≥4, 9 DCI) were monitored during 6.4 [4-8] days (min=2d, max=13d). AT/D changes could follow three different patterns: (1) prolonged or (2) transient decrease and (3) no decrease or progressive increase. A regional 30% decrease outlasting 3.7h reached 100% sensitivity and 88.9% specificity to detect DCI. Only 22.6% were in a zone of uncertain diagnosis (3.7-8.04h). These prolonged decreases, with a loss of transient changes, started in cortical areas evolving toward DCI, and preceded intracranial changes when available. ConclusionAlthough this study has a small sample size, prolonged AT/D decrease seems to be a reliable biomarker of DCI. Significance cEEG changes are likely to precede cerebral infarction and could be useful at the bedside to detect DCI before irreversible damage. Highlights1. An EEG montage matching vascular territories is relevant to monitor subarachnoid hemorrhage patients. 2. Prolonged alpha-theta/delta ratio (AT/D) decrease starting in one territory seems to be a good biomarker of delayed cerebral ischemia. 3. Other AT/D patterns and EEG changes can complement daily neurological examination.</div