Ischaemic Haemorrhagic Stroke in a Child with New Onset Type 1 Diabetes Mellitus

Cerebral oedema is the most common neurological complication of diabetic ketoacidosis (DKA). However, ischaemic and haemorrhagic brain injury has been reported infrequently. A 10-year old girl who was previously well presented with severe DKA. She was tachycardic with poor peripheral perfusion but normotensive. However, two fast boluses totalling 40 ml/kg normal saline were given. She was transferred to another hospital where she was intubated due to drowsiness. Rehydration fluid (maintenance and 48-hour correction for 7.5% dehydration) was started followed by insulin infusion. She was extubated within 24 hours of admission. Her ketosis resolved soon after and subcutaneous insulin was started. However, about 48 hours after admission, her Glasgow Coma Scale score dropped to 11/15 (E4M5V2) with expressive aphasia and upper motor neuron signs. One dose of mannitol was given. Her symptoms improved gradually and at 26-month follow-up she had a near-complete recovery with only minimal left lower limb weakness. Serial magnetic resonance imaging brain scans showed vascular ischaemic injury at the frontal-parietal watershed regions with haemorrhagic transformation. This case reiterates the importance of monitoring the neurological status of patient’s with DKA closely for possible neurological complications including an ischaemic and haemorrhagic stroke.

Download Full-text

Neurological complications and pathogenetic therapy for chronic nitrous oxide intoxication (“laughing gas”) in nightclub visitors

Neuromuscular Diseases ◽

10.17650/2222-8721-2020-10-3-49-62 ◽

2020 ◽

Vol 10 (3) ◽

pp. 49-62

Author(s):

N. А. Suponeva ◽

D. А. Grishina ◽

D. А. Grozova ◽

N. V. Belova ◽

М. А. Ginzberg ◽

...

Keyword(s):

Nitrous Oxide ◽

Neurological Complication ◽

Neurological Complications ◽

Vitamin B ◽

Aged People ◽

Laughing Gas ◽

Pathogenetic Therapy ◽

Vitamin Level ◽

Sensory Polyneuropathy

Background. Nitrous oxide abuse (“laughing gas”, N2O) is common among young people attending nightclubs. Contrary to popular belief about the safety of N2O, in some cases neurological complications develop due to a deficiency of vitamin B12, the activity of which is blocked by N2O. Purpose of the study – to determine the typology and course of neurological disorders in a group of patients who regularly use “laughing gas”. To note the key diagnostic markers that allow verification of vitamin B12 deficiency induced by nitrous oxide consumption. To describe pathogenetic therapy features and follow-up. Materials and methods. The study included 12 patients (10 men and 2 women) aged 18 to 45 years (average age 29 years) with a diagnosis of B12-deficient myelopolyneuropathy induced by regular use of nitrous oxide. Results. The most common neurological complication of nitrous oxide abuse for more than 1 month was a generalized lesion of the peripheral nerves with acute or subacute distal symmetric sensory or sensorimotor axonal polyneuropathy. In the clinical picture, sensory complaints and disorders prevailed. Paresis developed in half of the cases. A typical neuroimaging symptom characteristic of funicular myelosis was rarely detected (16.7 %). A decrease in B12 vitamin level could most reliably be diagnosed only indirectly, by the presence of hyperhomocysteinemia (91.7 % of cases). In all cases that were followed-up, prolonged therapy with cyanocobalamin led to partial (n = 5; 62.5 %) or complete (n = 3; 37.5 %) regression of neurological symptoms. Conclusion. Caution regarding the use of nitrous oxide should be in all cases of predominantly sensory polyneuropathy with acute or subacute development in young and middle-aged people. A thorough history taking (targeted survey on the fact of nitrous oxide consumption) and diagnostics (testing the level of homocysteine, if possible methylmalonic acid) allow you to not miss a deficiency of vitamin B12, the treatment of the consequences of which with timely verification and adequate correction is quite effective. It is recommended that the level of homocysteine in the blood to be regularly monitored during the treatment (in order to achieve its normalization).

Download Full-text

Delayed postoperative neurological complication in a patient with congenital kyphoscoliosis: recovered by revision of the 4-rod instrumentation technique

Journal of Neurosurgery Spine ◽

10.3171/2013.8.spine121160 ◽

2013 ◽

Vol 19 (5) ◽

pp. 595-599 ◽

Cited By ~ 1

Author(s):

Pooya Javidan ◽

Nima Kabirian ◽

Gregory M. Mundis ◽

Behrooz A. Akbarnia

Keyword(s):

Neurological Complication ◽

Posterior Spinal Fusion ◽

Neurological Status ◽

Neurological Deficits ◽

Preoperative Risk ◽

Preoperative Risk Assessment ◽

Rod System ◽

Proximal Extension ◽

Junctional Kyphosis

The authors report a case of progressive congenital kyphoscoliosis in which the patient, a boy, originally underwent combined anterior and instrumented posterior spinal fusion at the age of 7 years and 3 months. Early proximal junctional kyphosis and implant failure mandated proximal extension of implants with 2 new rods connected to the old caudad short rods. At the 3-year follow-up, clinical and CT assessment revealed a thoracolumbar pseudarthrosis for which the patient underwent a 2-stage procedure without complication. Recordings of somatosensory evoked potentials intraoperatively were normal. Twelve hours after surgery, his neurological status started to progressively deteriorate. The patient was brought to the operating room, and the initially achieved correction was reversed by an apex-only exposure of the 4-rod system. After surgery the patient started to show progressive improvement in his neurological function. A final myelography was performed and showed free passage of the dye without evidence of obstruction. Clinically, the patient continued to improve and at his 3-month follow-up had near-complete resolution of his neurological deficits. Findings on his physical examination were normal at the final 12-year follow-up. Despite normal findings on intraoperative neuromonitoring, a delayed neurological deficit can occur after complex spine reconstruction. Preoperative risk assessment, surgical approach, and instrumentation deserve careful attention. Advantages of a 4-rod construct are discussed in this case.

Download Full-text

Acute axonal polyneuropathy with predominant proximal involvement: an uncommon neurological complication of bariatric surgery

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2006000400017 ◽

2006 ◽

Vol 64 (3a) ◽

pp. 609-612 ◽

Cited By ~ 9

Author(s):

Flavia Costa Nunes Machado ◽

Berenice Cataldo Oliveira Valério ◽

Roberto Naun Franco Morgulis ◽

Karlo Faria Nunes ◽

Sílvia Mazzali-Verst

Keyword(s):

Bariatric Surgery ◽

Morbid Obesity ◽

Neurological Complication ◽

Neurological Complications ◽

Gastric Surgery ◽

Lower Limbs ◽

Vitamin Supplementation ◽

Axonal Polyneuropathy ◽

Peripheral Polyneuropathy

Bariatric surgery is frequently indicated in the treatment of morbid obesity. Previously unreported complications have been associated to this surgery; among them, neurological complications have gained attention. We report the case of a 25-year-old man submitted to gastric surgery for treatment of morbid obesity who developed, two months after surgery, acute proximal weakness in lower limbs. The electroneuromyography revealed axonal peripheral polyneuropathy with predominant proximal involvement. After treatment with immunoglobulin and vitamin supplementation, rapid clinical and neurophysiologic recovery was observed. We describe the clinical and electroneuromyographic features of this case, stressing the difficulty of initial diagnosis, particularly in the differential diagnosis with Guillain-Barré syndrome. We discuss the importance of nutritional follow-up and the eventual indication of routine vitamin supplementation in these patients.

Download Full-text

Anterior expandable strut cage replacement for osteoporotic thoracolumbar vertebral collapse

Journal of Neurosurgery Spine ◽

10.3171/spi.2006.4.6.454 ◽

2006 ◽

Vol 4 (6) ◽

pp. 454-462 ◽

Cited By ~ 48

Author(s):

Kenzo Uchida ◽

Shigeru Kobayashi ◽

Hideaki Nakajima ◽

Yasuo Kokubo ◽

Takafumi Yayama ◽

...

Keyword(s):

Neurological Status ◽

Neurological Deficits ◽

Vertebral Body Replacement ◽

Vertebral Collapse ◽

Expandable Cage ◽

Cage Subsidence ◽

The Mean ◽

Type 3

Object The authors investigated the usefulness of using an expandable cage strut in anterior reconstruction after osteoporotic vertebral collapse in patients with neurological deficits. Methods Twenty-eight patients who had undergone expandable cage strut–augmented anterior thoracolumbar reconstruction participated in a follow-up review for a mean of 4.9 years. Radiographs were reviewed for kyphosis, lateral tilt of the implant, cage subsidence, the presence of a solid fusion mass, and instrumentation failure. Changes in neurological status and visual analog scale (VAS) pain score, as well as technique-related complications, were examined. The mean angles ± the standard deviations of kyphosis correction 4 to 6 weeks after surgery and at final follow-up examination were 10.4 ± 7.6° and 5.6 ± 6.0°, respectively. The mean subsidence of the expandable cage within the adjacent vertebrae was 2.5 ± 3.0 mm at the final follow-up examination. Neurological improvement at the final follow up was more significant in patients with Type 1 (wedge-type) than Type 2 (flat-type) (p = 0.037) or Type 3 (concave-type) (p = 0.006) vertebral collapse. Follow-up VAS scores were significantly higher in patients with Type 1 than Type 3 collapse (p = 0.012). In all cases the authors observed solid union with incorporation of the cage. There were no surgery-related complications. Conclusions An expandable titanium cage strut seems useful in vertebral body replacement in patients with osteoporotic thoracolumbar collapse. Favorable results were obtained in cases of Type 1 collapse (wedge type) in which the middle and posterior columns remained comparatively intact.

Download Full-text

Treatment of posterior circulation fusiform aneurysms

Journal of Neurosurgery ◽

10.3171/2020.4.jns192838 ◽

2020 ◽

pp. 1-7

Author(s):

Ephraim W. Church ◽

Mark G. Bigder ◽

Eric S. Sussman ◽

Santosh E. Gummidipundi ◽

Summer S. Han ◽

...

Keyword(s):

Neurological Complication ◽

Posterior Inferior Cerebellar Artery ◽

Retrospective Chart Review ◽

Neurological Complications ◽

Posterior Circulation ◽

Flow Diversion ◽

Interdisciplinary Treatment ◽

Complication Rates ◽

The Difference

OBJECTIVEPerforator arteries, the absence of an aneurysm discrete neck, and the often-extensive nature of posterior circulation fusiform aneurysms present treatment challenges. There have been advances in microsurgical and endovascular approaches, including flow diversion, and the authors sought to review these treatments in a long-term series at their neurovascular referral center.METHODSThe authors performed a retrospective chart review from 1990 to 2018. Primary outcomes were modified Rankin Scale (mRS) scores and Glasgow Outcome Scale (GOS) scores at follow-up. The authors also examined neurological complication rates. Using regression techniques, they reviewed independent and dependent variables, including presenting features, aneurysm location and size, surgical approach, and pretreatment and posttreatment thrombosis.RESULTSEighty-four patients met the inclusion criteria. Their mean age was 53 years, and 49 (58%) were female. Forty-one (49%) patients presented with subarachnoid hemorrhage. Aneurysms were located on the vertebral artery (VA) or posterior inferior cerebellar artery (PICA) in 50 (60%) patients, basilar artery (BA) or vertebrobasilar junction (VBJ) in 22 (26%), and posterior cerebral artery (PCA) in 12 (14%). Thirty-one (37%) patients were treated with microsurgical and 53 (63%) with endovascular approaches. Six aneurysms were treated with endovascular flow diversion. The authors found moderate disability or better (mRS score ≤ 3) in 85% of the patients at a mean 14-month follow-up. The GOS score was ≥ 4 in 82% of the patients. The overall neurological complication rate was 12%. In the regression analysis, patients with VA or PICA aneurysms had better functional outcomes than the other groups (p < 0.001). Endovascular strategies were associated with better outcomes for BA-VBJ aneurysms (p < 0.01), but microsurgery was associated with better outcomes for VA-PICA and PCA aneurysms (p < 0.05). There were no other significant associations between patient, aneurysm characteristics, or treatment features and neurological complications (p > 0.05). Patients treated with flow diversion had more complications than those who underwent other endovascular and microsurgical strategies, but the difference was not significant in regression models.CONCLUSIONSPosterior circulation fusiform aneurysms remain a challenging aneurysm subtype, but an interdisciplinary treatment approach can result in good outcomes. While flow diversion is a useful addition to the armamentarium, traditional endovascular and microsurgical techniques continue to offer effective options.

Download Full-text

Timing and Spectrum of Neurological Complications After Flow Diverter Implantation for Intracranial Aneurysms

Frontiers in Neurology ◽

10.3389/fneur.2021.590383 ◽

2021 ◽

Vol 12 ◽

Author(s):

Guillaume Charbonnier ◽

Jean-Philippe Desilles ◽

Simon Escalard ◽

Benjamin Maier ◽

Gabriele Ciccio ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Neurological Complication ◽

Neurological Complications ◽

Flow Diverter ◽

Factors Associated ◽

Long Term Follow Up ◽

Ischemic Complications ◽

Ischemic Events

Background and Purpose: The aim of this study was to characterize neurological complications after flow diverter (FD) treatment on a long follow-up cohort and identify predictive factors associated with these complications.Methods: This study was conducted on a monocentric cohort of patients treated for intracranial aneurysms by FD.Results: Between September 2008 and July 2018, 413 patients were treated for 514 aneurysms: 18% of the patients presented with at least one neurological complication during a median follow-up of 446 days (IQR 186–1,210). Sixty-one patients presented with ischemic complications, 13 with hemorrhagic ones and 10 with compressive processes. Among 89 neurological complications 64.5% were peri-operative (occurring within the 30 days following the procedure) and 35.5% were delayed after 1 month.Conclusions: Overall, neurological complications after FD implantation were overrepresented by cerebrovascular ischemic events occurring during the peri-operative period, but also in a delayed manner after 1 year. Long-term follow-up is relevant after aneurysm intervention using FD.

Download Full-text

Hemorrhagic Posterior Reversible Encephalopathy Syndrome: A Rare Neurological Complication of COVID-19 Infection

International Clinical Neuroscience Journal ◽

10.34172/icnj.2021.30 ◽

2021 ◽

Vol 8 (3) ◽

pp. 149-152

Author(s):

Esmaeil KhanMohammadi ◽

Marziyeh Shahrabi ◽

Mohsen Koosha

Keyword(s):

Posterior Reversible Encephalopathy Syndrome ◽

Neurological Complication ◽

Neurological Complications ◽

Convulsive Status Epilepticus ◽

Posterior Reversible Encephalopathy ◽

Cerebrovascular Complication ◽

History Of ◽

Reversible Encephalopathy ◽

Hypertensive Therapy

Neurological complications of COVID-19 are well documented. However, there are limited reports of posterior reversible encephalopathy syndrome (PRES) associated with COVID-19 in the literature. Herein, we described a 21-year-old man with a history of bipolar disease and opioid addiction who was admitted because of COVID-19 infection. He suddenly experienced a convulsive status epilepticus following hypertension crisis. The patient was intubated and underwent antiepileptic and anti-hypertensive therapy. His brain imaging was compatible with PRES. The patient gradually improved and was eventually discharged after 40 days. On the next month follow-up, the patient was able to walk with a cane without a history of seizure. In this report, we aimed to highlight the less common cerebrovascular complication of COVID-19 infection.

Download Full-text

Moyamoya syndrome associated with neurofibromatosis Type 1: perioperative and long-term outcome after surgical revascularization

Journal of Neurosurgery Pediatrics ◽

10.3171/2012.12.peds12281 ◽

2013 ◽

Vol 11 (4) ◽

pp. 417-425 ◽

Cited By ~ 37

Author(s):

McKenzie Koss ◽

R. Michael Scott ◽

Mira B. Irons ◽

Edward R. Smith ◽

Nicole J. Ullrich

Keyword(s):

Perioperative Complications ◽

Neurofibromatosis Type ◽

Neurological Status ◽

Neurological Deficits ◽

Moyamoya Syndrome ◽

Surgical Revascularization ◽

Radiographic Evidence

Object Children with neurofibromatosis Type 1 (NF1) can present with progressive arteriopathy of the branches of the internal carotid artery consistent with moyamoya syndrome. Clinical symptoms, radiographic evidence of ischemia, and the potential for disease progression may necessitate surgical revascularization to minimize the risk of stroke and progressive neurological deficits. This study aims to evaluate the presentation and surgical outcomes of these patients by reviewing clinical, radiographic, and angiographic data. Methods A retrospective review was conducted of clinical and radiographic records of all children with NF1 who were diagnosed with moyamoya syndrome and underwent surgical revascularization between January 1988 and April 2012 at Boston Children's Hospital. Results During this period, 39 patients (27 female and 12 male, ages 0.2–19.3 years) had both NF1 and moyamoya syndrome, of whom 32 underwent surgical revascularization with pial synangiosis. Of the 32 patients treated by surgical revascularization, 21 (66%) manifested ischemic symptoms and 18 (56%) had radiographic evidence of prior stroke at the time of moyamoya diagnosis. In total, 25 of 32 patients developed neurological symptoms prior to surgical intervention. Only 1 patient presented with hemorrhage. The average age at first surgery was 8.1 years (range 0.5–15.6 years). Perioperative complications in the first 7 days included stroke (n = 2), transient ischemic attack (n = 1), and infection (n = 1). Twenty-two patients had more than 6 months of follow-up, with an average clinical and radiographic postoperative follow-up period of 80.2 months (range 9.4–257.1 months). Of those patients with long-term follow-up, 21 (95%) of 22 demonstrated stable or improved neurological status despite radiographic evidence of moyamoya progression in 48% of patients. Conclusions Children with NF1-associated moyamoya syndrome are often diagnosed prior to development of fixed neurological deficits as a consequence of imaging studies obtained for other manifestations of NF1. The clinical, radiographic, and angiographic features in this population are comparable to primary moyamoya disease, with the exception of patients treated with cranial irradiation, who may be at greater risk for both stroke as well as perioperative complications. Despite radiographic evidence of progressive stenosis in 48% of patients, nearly all demonstrated stable or improved neurological status after surgical revascularization. Surgical revascularization for children with NF1 appears safe and is protective against further ischemic and neurological damage, with a 27-fold reduction in stroke rate.

Download Full-text

Cauda Equina Syndrome Retention Type –Late Intervention Can also give Excellent Results

10.47363/jnrrr/2020(2)125 ◽

2020 ◽

pp. 1-4

Author(s):

Suhasish Roy ◽

◽

Siddhartha Mahapatra ◽

Keyword(s):

Disc Herniation ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Golden Rule ◽

Complete Recovery ◽

Neurological Status ◽

Bowel Dysfunction ◽

Caries Spine ◽

Bladder Bowel Dysfunction

Introduction: Cauda Equina Syndrome (CES) is an acute stenosis of lumbar spinal canal leading to compression of neural elements below the level of L1 mostly due to disc herniation but other causes exist. Intervention within 48 hours prevent permanent sensorimotor, sphincter and sexual disturbances. We reporttwelvecases of Cauda Equina Syndrome with complete sensorimotor deficit, bladder, bowel dysfunction intervened at least 1 month after initiation of symptoms with complete recovery of functions. Till date a few literature support is there to substantiate this evidence. Methods: 22 patients between 2011 to 2015, 18 male and 4 female, attended with complete or retention type of cauda equina syndrome. Of the 8 men, 5 had acute discherniations, 2 had caries spine, 1 had trauma. Of the 4 women,3 had acute disc herniation,1 had caries spine. 4 attended 35- 39 days, 4 between 45- 45 days,4 between 45- 60 days. They were urgently decompressed within 72 hours of attendance. 4 were lost in follow- up within 1 year. Rest were followed up3- 5 years. Results: 3 patients improved by 14 to 28 days, their neurological status improved from ASIA A to ASIA D, 4 patients by 30 to 90 days from ASIA A to ASIA E. 1 male patient improved from ASIA A to ASIA C in 3 years. All the above neurological status maintained. 2 men and 2 women were lost to follow up within 1 year when their improvement were by only one grade in ASIA impairment scale. 7 out of 8 patients had excellent results. Conclusion: Though early intervention is the golden rule, in late presentations of complete cauda equine syndrome, thorough decompression improves the neurological status of the patient

Download Full-text

Endocarditis-related stroke is not a contraindication for early cardiac surgery: an investigation among 440 patients with left-sided endocarditis

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa239 ◽

2020 ◽

Vol 58 (6) ◽

pp. 1161-1167

Author(s):

Elfriede Ruttmann ◽

Hannes Abfalterer ◽

Julian Wagner ◽

Michael Grimm ◽

Ludwig Müller ◽

...

Keyword(s):

Hospital Mortality ◽

Mortality Risk ◽

Neurological Complication ◽

Cerebral Haemorrhage ◽

Haemorrhagic Stroke ◽

Neurological Recovery ◽

Partial Recovery ◽

Recovery Potential

Abstract OBJECTIVES A treatment dilemma arises when surgery is indicated in patients with infective endocarditis (IE) complicated by stroke. Neurologists recommend surgery to be postponed for at least 1 month. This study aims to investigate the neurological complication rate and neurological recovery potential in patients with IE-related stroke. METHODS A total of 440 consecutive patients with left-sided IE undergoing surgery were investigated. During follow-up, neurological recovery was assessed using the modified Rankin scale and the Barthel index. Mortality was assessed with regression models adjusting for age. RESULTS The median follow-up time was 9.0 years. Patients with previous strokes were more likely to suffer from mitral valve endocarditis (29.5% vs 47.4%, P < 0.001). Symptomatic stroke was found in 135 (30.7%) patients; of them, 42 patients presented with complicated stroke (additional meningitis, haemorrhagic stroke or intracranial abscess). Driven by symptomatic stroke, the age-adjusted hospital mortality risk was 1.4-fold [95% confidence interval (CI) 0.74–2.57; P = 0.31] higher and the long-term mortality risk was 1.4-fold higher (95% CI 1.003–2.001; P = 0.048). Hospital mortality was higher in patients with complicated stroke (21.4% vs 9.7%; P = 0.06) only; however, mortality rates were similar comparing uncomplicated stroke versus no stroke. Among patients with complicated ischaemic strokes, the observed risk for intraoperative cerebral haemorrhage was 2.3% only and the increased hospital mortality was not driven by cerebral complications. In the long-term follow-up, full neurological recovery was observed in 84 out of 118 survivors (71.2%), and partial recovery was observed in 32 (27.1%) patients. Neurological recovery was lower in patients with complete middle cerebral artery stroke compared to other localization (52.9% vs 77.6%; P = 0.003). CONCLUSIONS Contrary to current clinical practice and neurological recommendations, early surgery in IE is safe and neurological recovery is excellent among patients with IE-related stroke. Clinical registration number local IRB UN4232 382/3.1 (retrospective study).

Download Full-text