Neurophysiological evaluation of segmental motor neuron function of the thoracic cord in chronic SCI.

STUDY DESIGN: Pilot study. OBJECTIVES: The aim of the study was to develop a neurophysiological method to diagnose the cranial as well as the caudal level of a complete thoracic spinal cord injury (SCI) with higher precision than today's protocols. SETTING: SCI unit Karolinska University Hospital, Stockholm, Sweden. METHODS: Bipolar needle electromyography was recorded in intercostal spaces of five patients with chronic, complete thoracic SCI. Tests were performed during rest, during voluntary activation and during activation of lower body spasticity. Magnetic resonance imaging (MRI) was performed in each patient according to a protocol optimized for imaging near metal implants. RESULTS: Three distinct patterns were found in each patient. Above the lesion we found voluntary activated, normal motor unit potentials (MUPs). At the neurological level and a varying number of segments below, denervated intercostal segments with fibrillation potentials and positive sharp waves appeared. Below the neurological level, normal MUP activated in concert with lower body spasticity was found. The number of denervated segments showed a significant correlation to the length of spinal cord discontinuity on MRI (r=0.97, P<0.05). CONCLUSION: Intercostal neurophysiology in combination with MRI optimized for imaging near metal implants can be used to determine the extent of a chronic complete thoracic SCI, both anatomically and functionally. The described method increases the sensitivity to detect delicate neurological changes related to the dynamic of the pathology that follows SCI and may be useful in analyzing outcome in clinical trials.

Immediate postoperative angiography after aneurysm clipping--implications for quality control and guidance of further management.

BACKGROUND: To determine the impact of postoperative angiography after aneurysm clipping on quality control and further management. METHODS: A recent consecutive series of n = 296 patients (186 females, 110 males, mean age 51 yrs) who underwent 324 craniotomies to clip 384 aneurysms was reviewed. New irregularities on postoperative angiographies were categorized as unrelated (e. g. vasospasm) or related (= vessel occlusion/residuum) to clipping and expected or unexpected by the surgeon. Therapies prompted by these findings as well as subsequent negative sequelae were analyzed. Factors related to negative events were identified by logistic regression (p < 0.05). RESULTS: Twenty-six (8%) unrelated findings prompted medical or intravascular therapy. Of 36 (9.4%) clip-related findings (n = 17 occlusions, n = 19 residua), 14 (3.6%) were unexpected (n = 9 occlusions, n = 5 residua). This was followed by 9 (2.3%, n = 4 occlusions, n = 5 residua) clip readjustments and 6 aggressive medical therapies. Nine patients were scheduled for angiographic follow-up, of which in five performed so far no change of aneurysm remnants was noted. Permanent sequelae from vessel occlusion occurred in 9 cases. Major premature rupture (p < 0.005), giant size/fusiform configuration (p < 0.001), posterior circulation aneurysms (p < 0.05) and ophthalmic segment location (p < 0.008) were significantly related to adverse postoperative findings. The use of microvascular Doppler significantly reduced the rate of unexpected vessel occlusion (3.3 vs. 0.9%). CONCLUSIONS: Apart from the need for quality control in aneurysm clipping--especially with respect to coiling--our results stress the importance of postoperative angiography, because a small, but significant subset of patients will benefit from immediate intervention and/or deserves long-term follow-up.