Intraoperative radial nerve injury during coronary artery surgery – report of two cases

BACKGROUND: Peripheral nerve injury and brachial plexopathy are known, though rare complications of coronary artery surgery. The ulnar nerve is most frequently affected, whereas radial nerve lesions are much less common accounting for only 3% of such intraoperative injuries. CASE PRESENTATIONS: Two 52- and 50-year-old men underwent coronary artery surgery. On the first postoperative day they both complained of wrist drop on the left. Neurological examination revealed a paresis of the wrist and finger extensor muscles (0/5), and the brachioradialis (4/5) with hypoaesthesia on the radial aspect of the dorsum of the left hand. Both biceps and triceps reflexes were normoactive, whereas the brachioradialis reflex was diminished on the left. Muscles innervated from the median and ulnar nerve, as well as all muscles above the elbow were unaffected. Electrophysiological studies were performed 3 weeks later, when muscle power of the affected muscles had already begun to improve. Nerve conduction studies and needle electromyography revealed a partial conduction block of the radial nerve along the spiral groove, motor axonal loss distal to the site of the lesion and moderate impairment in recruitment with fibrillation potentials in radial innervated muscles below the elbow and normal findings in triceps and deltoid. Electrophysiology data pointed towards a radial nerve injury in the spiral groove. We assume external compression as the causative factor. The only apparatus attached to the patients' left upper arm was the sternal retractor, used for dissection of the internal mammary artery. Both patients were overweight and lying on the operating table for a considerable time might have caused the compression of their left upper arm on the self retractor's supporting column which was fixed to the table rail 5 cm above the left elbow joint, in the site where the radial nerve is directly apposed to the humerus. CONCLUSION: Although very uncommon, external compression due to the use of a self retractor during coronary artery surgery can affect – especially in obese subjects – the radial nerve within the spiral groove leading to paresis and should therefore be included in the list of possible mechanisms of radial nerve injury

Headache during airplane travel (“airplane headache”): first case in Greece

Headache related to airplane flights is rare. We describe a 37-year-old female patient with multiple intense, jabbing headache episodes over the last 3 years that occur exclusively during airplane flights. The pain manifests during take-off and landing, and is located always in the left retro-orbital and frontotemporal area. It is occasionally accompanied by dizziness, but no additional symptoms occur. Pain intensity diminishes and disappears after 15–20 min. Apart from occasional dizziness, no other symptoms occur. The patient has a history of tension-type headache and polycystic ovaries. Blood tests and imaging revealed no abnormalities. Here, we present the first case in Greece. We review the current literature on this rare syndrome and discuss on possible pathophysiology and the investigation of possible co-factors such as anxiety and depression

Etiology and outcome of stroke in young adults

Stroke is a heterogeneous disease of the elderly. Only 5% of strokes occur before the age 45. Aim of the present prospective observational study was to classify different strokes subtypes among Greek patients aged less than 45 and to evaluate risk factor profiles and outcome parameters. A total of 176 stroke patients with a mean age of 36.3 years were included in our study. Men (53.4%) outnumbered women slightly. Most patients (63.6%) suffered ischemic strokes, whereas in 21% of all cases transient ischemic attacks were diagnosed. Intracerebral and subarachnoid hemorrhages were diagnosed in 6.3% and 5.1% respectively Focusing on ischemic stroke, atherothrombotic large vessel disease caused only 4.4%, whereas 17% of all infarcts were of cardioembolic etiology. It should be noted that 68% of cardioembolic strokes were associated with congenital defects of the atrial septum. Lacunar stroke was documented in only 12.5%. Almost every fourth case of cerebral infarction was of another determined etiology. Finally, in 40.2% of cases no exact etiology could be determined. Smoking, arterial hypertension and hypercholesterolemia were the most frequently documented vascular risk factors. It needs to be underlined that only 34.8 and 1.3% of hypertensive and hyperlipidemic patients were on the appropriate preventive medication at the stroke onset. Only three deaths due to extended brain damage occurred during the first month after stroke. During the same period no death was documented in the subgroup of ischemic stroke. The overall one-year mortality of 2.4% is judged as very low. Regarding course and rehabilitation our patients showed an excellent outcome. Only 15.2% presented at the end of follow-up some kind of disability. When comparing with a control group of 327 older stroke patients (mean age 64.4) we found statistically significant lower frequencies of all classical vascular risk factors. On the other hand systemic and hematologic diseases were statistically more frequent among younger patients. There were no significant differences between both age groups in terms of stroke subtypes and outcome measures. However, it should be noted that females were statistically more affected in the younger age group. Moreover females outnumbered males significantly (61.4% vs. 38.6%) in the age subgroup below 30. Review of the current literature leads to the general conclusion that our findings do not differ substantially from similar data from various other countries. We need to underline the extremely high percentage of active smokers, which is by far the highest mentioned yet. The female predominance at ages below 30 years is another interesting finding that has also been previously reported in some styles from Nordic and Mediterranean countries. Racial factors may influence the involvement of both sexes in cerebrovascular diseases.Τα Αγγειακά Εγκεφαλικά Επεισόδια (ΑΕΕ) αποτελούν μια ετερογενή ομάδα παθήσεων που χαρακτηρίζει τη μεγάλη ηλικία. Μόλις το 5% του συνόλου αφορά ηλικίες μέχρι 45 ετών. Σκοπός της προοπτικής αυτής μελέτης παρατήρησης ήταν η ταξινόμηση των διαφόρων τύπων ΑΕΕ σε δείγμα Ελλήνων ασθενών ηλικίας μέχρι 45 ετών και η ανάλυση των στοιχείων που αφορούν την αιτιοπαθογένεια και την έκβαση τους. Ο πληθυσμός της παρούσας μελέτης αποτελείται από 176 ασθενείς μέσης ηλικίας 36.33 ετών με ΑΕΕ, εκ των οποίων 53.4% ήταν άνδρες. Στην πλειονότητα των περιπτώσεων διαγνώστηκε ισχαιμικό ΑΕΕ (63.6%) ενώ παροδικό ισχαιμικό ΑΕΕ καταγράφηκε στο 21.0%. Ενδοεγκεφαλική και υπαραχνοειδής αιμορραγία διαπιστώθηκε στο 6.3% και 5.1% αντίστοιχα. Μεταξύ των ισχαιμικών ΑΕΕ μόλις το 4.4% αποδόθηκε σε αθηρωθρομβωτική νόσο, ενώ καρδιοεμβολικής αιτιολογίας ήταν το 17%. Αξίζει να επισημανθεί ότι το 68% των καρδιοεμβολικών. Κενοχωρικά έμφρακτα σε διαγνώστηκαν στο 12.5%, ενώ σε άλλη επιβεβαιωμένη αιτιολογία αποδόθηκε το 25.9% των περιπτώσεων. Τέλος, το ποσοστό των περιπτώσεων που δεν κατέστη δυνατό να καθοριστεί το ακριβές αίτιο έφτασε το 40.2%. Το κάπνισμα, η υπερχοληστερολαιμία και η αρτηριακή υπέρταση αποτέλεσαν με 59.7%, 45.5% και 26.1% αντίστοιχα τους σημαντικότερους παράγοντες κινδύνου. Τα ποσοστά των ασθενών που λάμβαναν την κατάλληλη αντιυπερτασική και αντιλιπιδαιμική αγωγή ήταν με 34.8% και 1.3% απογοητευτικά. Εντός του πρώτου μήνα καταγράφηκαν 3 θάνατοι συνεπεία βαριάς εγκεφαλικής βλάβης. Εντός του πρώτου έτους καταγράφηκε ακόμη ένας θάνατος άλλης αιτιολογίας. Η θνητότητα εντός του πρώτου έτους έφτασε το 2.4%. Στην πλειονότητα των ασθενών παρατηρήθηκε εξαιρετική κλινική αποκατάσταση, ενώ μόλις το 15.2% παρουσίασε υπολειμματική αναπηρία. Συγκρίνοντας με δείγμα 327 ασθενών μέσης ηλικίας 64.4 ετών) διαπιστώσαμε μεταξύ των ηλικιακά νεότερων στατιστικώς σημαντικά χαμηλότερα ποσοστά κλασσικών παραγόντων κινδύνου και υψηλότερα ποσοστά συστηματικών νοσημάτων και αιματολογικών/θρομβοφιλικών διαταραχών. Δε διαπιστώσαμε στατιστικώς σημαντικές διαφορές που να αφορούν τη συχνότητα εμφάνισης των διαφόρων τύπων ΑΕΕ ή την κλινική έκβαση. Πρέπει να επισημανθεί το στατιστικώς σημαντικά υψηλότερο ποσοστό των γυναικών στις ηλικίες μέχρι 45 ετών, καθώς και η σαφής υπεροχή τους (61.4% vs. 38.6%) στις ηλικίες μέχρι 30 ετών. Σε σύγκριση με τη διεθνή βιβλιογραφία ο υπό μελέτη πληθυσμός ασθενών με ΑΕΕ ηλικίας μέχρι 45 ετών δεν παρουσιάζει ουσιαστικές διαφορές. Θα πρέπει να υπογραμμιστεί το εξαιρετικά υψηλό και συγκριτικά με άλλες χώρες μακράν υψηλότερο ποσοστό ενεργών καπνιστών, καθώς επίσης και η σαφής υπεροχή των γυναικών στις μικρότερες ηλικίες, εύρημα το οποίο έχει επισημανθεί σε πολύ μικρό αριθμό μελετών, γεγονός που καθιστά πιθανό και τον ρόλο φυλετικών παραμέτρων

Magnetic resonance imaging findings in a case of stroke-related peduncular hallucinosis

Background: Peduncular hallucinosis is a rare stroke-related phenomenon that may occur in cases of ischemic lesions localized in the cerebral peduncles, the pons, the upper midbrain or the thalamus and is mostly characterized by transient visual hallucinations. Case presentation: We report the case of an insufficiently treated hypertensive patient who presented with constantly elevated blood pressure values and persistent visual hallucinations, which ceased a few hours later after medically achieved blood pressure normalization. Magnetic resonance imaging (MRI) revealed a symmetric paramedian ischemic lesion of the upper pons, which seems to be the cause of this case of peduncular hallucinosis. Conclusion: Although uncommon, this entity needs to be differential diagnostically considered in cases of transient visual hallucinations in persons with known vascular risk profile. MRI can be a useful diagnostic tool

Memantine and NMDA antagonism for chronic migraine: A potentially novel therapeutic approach?

We present the case of a woman with chronic migraine who unexpectedly reported full remission of headache after memantine, an NMDA receptor antagonist, was administered for treating concomitant mild cognitive impairment. An underlying dose-dependent effect of memantine on headache symptoms in chronic daily headache and chronic migraine could be assumed

Blood pressure management in acute stroke: A long-standing debate

Although elevated blood pressure (BP) levels are a common complication of acute stroke, whether of ischaemic or haemorrhagic type, a long-standing debate exists regarding the management of post-stroke hypertension. In the absence of solid, randomised data from controlled trials, the current observational evidence allows different approaches, since theoretical arguments exist for both lowering BP in the setting of acute stroke (reduce the risk of stroke recurrence, of subsequent oedema formation, of rebleeding and haematoma expansion in patients with cerebral bleeding) as well as leaving raised BP levels untreated (avoid reduction in cerebral perfusion pressure and blood flow to viable ischaemic tissue in the absence of normal autoregulation). The present review will summarize the evidence for and against the therapeutic manipulation of BP in acute stroke provided by the currently available observational studies and randomised trials, consider the ongoing clinical trials in this area and address the present recommendations regarding this conflicting issue. Copyright (c) 2006 S. Karger AG, Basel

The Emerging Role of microRNA in Stroke

MicroRNAs (miRNAs) are small non-coding RNAs approximately 22 nucleotides in length that play a pivotal role in post-transcriptional gene regulation by binding to complementary sites in the 3’-untranslated region of messenger RNAs. In the past decade, their role in several human diseases, from cancer to cardiovascular disease, has been established by a wealth of evidence. Stroke is responsible for 10% of deaths worldwide and is one of the leading causes of disability. MiRNAs are involved in stroke risk factors including hypertension, atherosclerosis, atrial fibrillation, diabetes and dyslipidemia. The role of miRNAs in the pathophysiology of stroke has been the subject of more recent investigations. Animal studies, which dominate the field, have demonstrated the differential expression of miRNAs in brain and blood following ischemic or hemorrhagic insult and the potential use of miRNA antagonists to reduce focal cerebral damage. In particular, antagomirs to miR-145, -497, -181a, -1 and let-7f have been found to be neuroprotective in vivo. The discovery of circulating miRNAs in peripheral blood, which are unexpectedly stable, has allowed the recent completion of several studies in human stroke patients that have confirmed the differential expression of specific miRNAs following stroke and have addressed their potential use as diagnostic and prognostic markers. With miRNA research in stroke still in its infancy, it is anticipated that in the next few years significant discoveries that may have important therapeutic implications will emerge