Spot sign score is associated with hematoma expansion and longer hospital stay but not functional outcomes in primary intracerebral hemorrhage survivors.

PURPOSE: The computed tomography angiography (CTA) spot sign is a validated predictor of 30-day mortality in intracerebral hemorrhage (ICH). However, its role in predicting unfavorable functional outcomes remains unclear. This study explores the frequency of the spot sign and its association with functional outcomes, hematoma expansion, and length of hospital stay among survivors of ICH. MATERIALS AND METHODS: This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h of admission to two medical centers between January 2007 and August 2022. Patients who died before discharge and those referred from other hospitals were excluded. Spot signs were assessed by an experienced neuroradiologist. Functional outcomes were determined by modified Rankin Scale (mRS) scores and the Barthel Index (BI). RESULTS: In total, 98 patients were included; 14 (13.64%) had a spot sign. No significant differences were observed in the baseline characteristics between the patients with and without a spot sign. Higher spot sign scores were associated with higher odds of experiencing hematoma expansion (p = 0.013, 95% CI = 1.16-3.55), undergoing surgery (p = 0.012, 95% CI = 0.19-1.55), and having longer hospital stay (p = 0.02, 95% CI = 1.22-13.92). However, higher spot sign scores were not associated with unfavorable functional outcomes (p = 0.918 for BI, and p = 0.782 for mRS). CONCLUSION: Spot signs are common findings among patients with ICH, and higher spot sign scores were associated with subsequent hematoma expansion and longer hospital stays but not unfavorable functional outcomes.

The Cortical and Subcortical Neural Control of Swallowing: A Narrative Review.

Swallowing is a sophisticated process involving the precise and timely coordination of the central and peripheral nervous systems, along with the musculatures of the oral cavity, pharynx, and airway. The role of the infratentorial neural structure, including the swallowing central pattern generator and cranial nerve nuclei, has been described in greater detail compared with both the cortical and subcortical neural structures. Nonetheless, accumulated data from analysis of swallowing performance in patients with different neurological diseases and conditions, along with results from neurophysiological studies of normal swallowing have gradually enhanced understanding of the role of cortical and subcortical neural structures in swallowing, potentially leading to the development of treatment modalities for patients suffering from dysphagia. This review article summarizes findings about the role of both cortical and subcortical neural structures in swallowing based on results from neurophysiological studies and studies of various neurological diseases. In sum, cortical regions are mainly in charge of initiation and coordination of swallowing after receiving afferent information, while subcortical structures including basal ganglia and thalamus are responsible for movement control and regulation during swallowing through the cortico-basal ganglia-thalamo-cortical loop. This article also presents how cortical and subcortical neural structures interact with each other to generate the swallowing response. In addition, we provided the updated evidence about the clinical applications and efficacy of neuromodulation techniques, including both non-invasive brain stimulation and deep brain stimulation on dysphagia.

Long COVID and rehabilitation.

Coronavirus disease 2019 (COVID-19) has caused tremendous morbidity and mortality worldwide. The large number of post-COVID survivors has drawn attention to the management of post-COVID condition, known as long COVID. This review examines current knowledge of long COVID, regarding its epidemiology, mechanism, and clinical presentations in both adults and children. We also review the rehabilitation principles, modules, and effects, and share Taiwan's efforts to provide a top-down, nationwide care framework for long COVID patients. Dyspnea, chronic cough, and fatigue are the most commonly reported symptoms in the first 6 months after infection, but cognitive impairment and psychological symptoms may persist beyond this time. Several possible mechanisms behind these symptoms were proposed, but remained unconfirmed. These symptoms negatively impact individuals' function, activities, participation and quality of life. Rehabilitation is a key element of management to achieve functional improvement. Early management should start with comprehensive evaluation and identification of red flags. Exercise-based therapy, an essential part of management of long COVID, can be conducted with different modules, including telerehabilitation. Post-exertional symptom exacerbation and orthostatic hypotension should be carefully monitored during exercise. Randomized control trials with a large sample size are needed to determine the optimal timing, dosage, and modules.

Early fever in patients with primary intracerebral hemorrhage is associated with worse long-term functional outcomes: a prospective study.

BACKGROUND: Primary intracerebral hemorrhage (ICH) accounts for 85% of ICH cases and is associated with high morbidity and mortality rates. Fever can cause secondary injury after ICH; however, relevant studies have reported inconsistent results regarding the effects of fever on functional outcomes after ICH. This study examined the effects of early fever on the prognosis of ICH, particularly on long-term functional outcomes. METHODS: This prospective study recruited patients with primary ICH at a tertiary medical center between 2019 and 2021. Early fever was defined as a tympanic body temperature of ≥ 38 °C upon admission. Barthel Index (BI) and modified Rankin scale (mRS) were examined at 1 year after ICH. A BI of ≤ 60 or mRS of ≥ 4 was considered as indicating severe disability. RESULTS: We included 100 patients, and early fever was significantly associated with less functional independence at 1 year post-ICH, as determined using the mRS (p = 0.048; odds ratio [OR] = 0.23), and with severe functional dependency at 1 year post-ICH, as determined using the BI (p = 0.043; OR = 3) and mRS (p = 0.045; OR = 3). In addition, patients with early fever had a longer length of hospital stay (p = 0.002; 95% confidence interval = 21.80-95.91). CONCLUSIONS: Fever is common among patients with primary ICH. Our data indicate a significant association between early fever and worse functional outcomes in ICH survivors at 1 year after ICH. Additionally, patients with early fever had a significantly longer length of hospital stay after ICH.

Update of Contrast-enhanced Ultrasound in Musculoskeletal Medicine: Clinical Perspectives - A Review.

Contrast-enhanced ultrasound (CEUS) uses an intravascular contrast agent to enhance blood flow signals and assess microcirculation in different parts of the human body. Over the past decade, CEUS has become more widely applied in musculoskeletal (MSK) medicine, and the current review aims to systematically summarize current research on the application of CEUS in the MSK field, focusing on 67 articles published between January 2001 and June 2021 in online databases including PubMed, Scopus, and Embase. CEUS has been widely used for the clinical assessment of muscle microcirculation, tendinopathy, fracture nonunions, sports-related injuries, arthritis, peripheral nerves, and tumors, and can serve as an objective and quantitative evaluation tool for prognosis and outcome prediction. Optimal CEUS parameters and diagnostic cut off values for each disease category remain to be confirmed.

The Hyoid Bone Kinematics in Dysphagic Stroke Patients: Instantaneous Velocity, Acceleration and Temporal Sequence Matters.

Hyoid bone excursion (HBE) is one of the most critical events in the pharyngeal phase of swallowing. Most previous studies focused on the total displacement and average velocity of HBE. However, HBE during swallowing is not one-dimensional, and the change of velocity and acceleration is not linear. This study aims to elucidate the relationship between the instantaneous kinematics parameters of HBE and the severity of penetration/aspiration and pharyngeal residue in patients with stroke. A total of 132 sets of video-fluoroscopic swallowing study images collected from 72 dysphagic stroke patients were analyzed. The maximal instantaneous velocity, acceleration, displacement, and the time required to reach these values in the horizontal and vertical axes were measured. Patients were grouped according to the severity of the Penetration-Aspiration Scale and the Modified Barium Swallow Impairment Profile- Pharyngeal Residue. The outcome was then stratified according to the consistencies of swallowing materials. Stroke patients with aspiration were associated with a lower maximal horizontal instantaneous velocity and acceleration of HBE, a shorter horizontal displacement, and prolonged time to maximal vertical instantaneous velocity compared to the non-aspirators. In patients with pharyngeal residue, the maximal horizontal displacement of HBE was decreased. After stratification according to bolus consistencies, the temporal parameters of HBE were more significantly associated with aspiration severity when swallowing thin bolus. Meanwhile spatial parameters such as displacement had a bigger influence on aspiration severity when swallowing viscous bolus. These novel kinematic parameters of HBE could provide important reference for estimating swallowing function and outcomes in dysphagic stroke patients.

Real-Time Automated Segmentation of Median Nerve in Dynamic Ultrasonography Using Deep Learning.

OBJECTIVE: The morphological dynamics of the median nerve across the level extracted from dynamic ultrasonography are valuable for the diagnosis and evaluation of carpal tunnel syndrome (CTS), but the data extraction requires tremendous labor to manually segment the nerve across the image sequence. Our aim was to provide visually real-time, automated median nerve segmentation and subsequent data extraction in dynamic ultrasonography. METHODS: We proposed a deep-learning model modified from SOLOv2 and tailored for median nerve segmentation. Ensemble strategies combining several state-of-the-art models were also employed to examine whether the segmentation accuracy could be improved. Image data were acquired from nine normal participants and 59 patients with idiopathic CTS. DISCUSSION: Our model outperformed several state-of-the-art models with respect to inference speed, whereas the segmentation accuracy was on a par with that achieved by these models. When evaluated on a single 1080Ti GPU card, our model achieved an intersection over union score of 0.855 and Dice coefficient of 0.922 at 28.9 frames/s. The ensemble models slightly improved segmentation accuracy. CONCLUSION: Our model has great potential for use in the clinical setting, as the real-time, automated extraction of the morphological dynamics of the median nerve allows clinicians to diagnose and treat CTS as the images are acquired.

Intercellular Calcium Waves and Permeability Change Induced by Vertically Deployed Surface Acoustic Waves in a Human Cerebral Microvascular Endothelial Cell Line (hCMEC/D3) Monolayer.

OBJECTIVE: The ultrasound-mediated blood-brain barrier (BBB) opening with microbubbles has been widely employed, while recent studies also indicate the possibility that ultrasound alone can open the BBB through a direct mechanical effect. However, the exact mechanisms through which ultrasound interacts with the BBB and whether it can directly trigger intracellular signaling and a permeability change in the BBB endothelium remain unclear. METHODS: Vertically deployed surface acoustic waves (VD-SAWs) were applied on a human cerebral microvascular endothelial cell line (hCMEC/D3) monolayer using a 33-MHz interdigital transducer that exerts shear stress-predominant stimulation. The intracellular calcium response was measured by fluorescence imaging, and the permeability of the hCMEC/D3 monolayer was assessed by transendothelial electrical resistance (TEER). DISCUSSION: At a certain intensity threshold, VD-SAWs induced an intracellular calcium surge that propagated to adjacent cells as intercellular calcium waves. VD-SAWs induced a TEER decrease in a pulse repetition frequency-dependent manner, thereby suggesting possible involvement of the mechanosensitive ion channels. CONCLUSION: The unique VD-SAW system enables more physiological mechanical stimulation of the endothelium monolayer. Moreover, it can be easily combined with other measurement devices, providing a useful platform for further mechanistic studies on ultrasound-mediated BBB opening.

Deep Learning for Automatic Hyoid Tracking in Videofluoroscopic Swallow Studies.

The hyoid bone excursion is one of the most important gauges of larynx elevation in swallowing, contributing to airway protection and bolus passage into the esophagus. However, the implications of various parameters of hyoid bone excursion, such as the horizontal or vertical displacement and velocity, remain elusive and raise the need for a tool providing automatic kinematics analysis. Several conventional and deep learning-based models have been applied automatically to track the hyoid bone, but previous methods either require partial manual localization or do not transform the trajectory by anatomic axis. This work describes a convolutional neural network-based algorithm featuring fully automatic hyoid bone localization and tracking and spine axis determination. The algorithm automatically estimates the hyoid bone trajectory and calculates several physical quantities, including the average velocity and displacement in horizontal or vertical anatomic axis. The model was trained in a dataset of 365 videos of videofluoroscopic swallowing from 189 patients in a tertiary medical center and tested using 44 videos from 44 patients with different dysphagia etiologies. The algorithm showed high detection rates for the hyoid bone. The results showed excellent inter-rater reliability for hyoid bone detection, good-to-excellent inter-rater reliability for calculating the maximal displacement and the average velocity of the hyoid bone in horizontal or vertical directions, and moderate-to-good reliability in calculating the average velocity in horizontal direction. The proposed algorithm allows for complete automatic kinematic analysis of hyoid bone excursion, providing a versatile tool with high potential for clinical applications.

Effect of Repetitive Transcranial Magnetic Stimulation on Post-stroke Dysphagia: A Meta-analysis of Stimulation Frequency, Stimulation Site, and Timing of Outcome Measurement.

Dysphagia is one of the most frequent sequelae of stroke. It can result in various complications such as malnutrition, dehydration, aspiration pneumonia, and poor rehabilitation outcomes. Repetitive transcranial magnetic stimulation (rTMS) has been reported to improve dysphagia after a stroke; however, effective treatment protocols have not been established yet. We evaluated the effect of the following rTMS parameters on post-stroke dysphagia: stimulation frequency [high frequency (≥ 3 Hz) or low frequency (1 Hz)] and stimulation site (ipsilesional or contralesional mylohyoid cortex). Outcomes were measured immediately, at 3 weeks, and at 4 weeks after the rTMS session. The PubMed, SCOPUS, Embase, and Cochrane Library databases were systematically searched for relevant studies published between January 01, 1980, and December 13, 2021. Randomized controlled trials on the effects of rTMS on post-stroke dysphagia were included. Six studies were finally included in the analysis. The selected studies included 158 patients (rTMS group: 81 patients; sham group: 77 patients). Regarding the effect of high-frequency rTMS on the ipsilesional cortex, the standardized swallowing assessment (SSA) scores showed significant improvement after rTMS sessions immediately and at 4 weeks [immediate: P = 0.02, standard mean difference (SMD) = - 0.61, 95% confidence interval (CI) = - 1.14 to - 0.08; 4 weeks: P = 0.006, SMD = - 0.74, 95% CI = - 1.27 to - 0.21]; however, there was no significant reduction in the Penetration-Aspiration Scale (PAS) scores between the rTMS and sham groups (immediate: P = 0.43, SMD = 0.25, 95% CI = - 0.36, 0.86; 3 weeks: P = 0.39, SMD = 0.37, 95% CI = - 0.47 to 1.22). After low-frequency rTMS on the ipsilesional cortex, a significantly greater improvement in the SSA scores was found in the rTMS group than in the sham group, both immediately and at 4 weeks after rTMS sessions (immediate: P = 0.03, SMD = - 0.59, 95% CI = - 1.12 to - 0.06; 4 weeks: P = 0.001, SMD = - 0.92, 95% CI = - 1.48 to - 0.37). In addition, immediately after the rTMS sessions, the PAS scores were significantly reduced in the rTMS group than in the sham group (P = 0.047, SMD = - 0.60, 95% CI = - 1.19 to - 0.01). However, at 4 weeks after rTMS sessions, there was no significant reduction in the PAS scores in the rTMS group compared to the sham group (P = 0.48, SMD = - 0.19, 95% CI = - 0.71 to 0.33). Both high-frequency rTMS of the ipsilesional cortex and low-frequency rTMS of the contralesional cortex improved some measurements of the swallowing function in stroke patients immediately and at 4 weeks after treatment.

Blood-cerebrospinal fluid barrier opening by modified single pulse transcranial focused shockwave.

Transcranial focused shockwave (FSW) is a novel noninvasive brain stimulation that can open blood-brain barriers (BBB) and blood-cerebrospinal fluid barriers (BCSFB) with a single low-energy (energy flux density 0.03 mJ/mm2) pulse and low-dose microbubbles (2 × 106/kg). Similar to focused ultrasound, FSW deliver highly precise stimulation of discrete brain regions with adjustable focal lengths that essentially covers the whole brain. By opening the BCSFB, it allows for rapid widespread drug delivery to the whole brain by cerebrospinal fluid (CSF) circulation. Although no definite adverse effect or permeant injury was noted in our previous study, microscopic hemorrhage was infrequently observed. Safety concerns remain the major obstacle to further application of FSW in brain. To enhance its applicability, a modified single pulse FSW technique was established that present 100% opening rate but much less risk of adverse effect than previous methods. By moving the targeting area 2.5 mm more superficially on the left lateral ventricle as compared with the previous methods, the microscopic hemorrhage rate was reduced to zero. We systemically examine the safety profiles of the modified FSW-BCSFB opening regarding abnormal behavior and brain injury or hemorrhage 72 hr after 0, 1, and 10 pulses of FSW-treatment. Animal behavior, physiological monitor, and brain MRI were examined and recorded. Brain section histology was examined for hemorrhage, apoptosis, inflammation, oxidative stress related immunohistochemistry and biomarkers. The single pulse FSW group demonstrated no mortality or gross/microscopic hemorrhage (N = 30), and no observable changes in all examined outcomes, while 10 pulses of FSW was found to be associated with microscopic and temporary RBC extravasation (N = 6/30), and abnormal immunohistochemistry biomarkers which showed a trend of recovery at 72 hrs. The results suggest that single pulse low-energy FSW-BCSFB opening is effective, safe and poses minimal risk of injury to brain tissue (Sprague Dawley, SD rats).

At Least 5-Year Outcomes of Whiplash-Induced Chronic Neck Pain Following Response to Intra-Articular Facet Joint Corticosteroid Injection.

Objective: To investigate whether the response to intra-articular facet joint corticosteroid injection can determine the long-term prognosis (at least 5 years after injury) of whiplash injury-related neck pain sustained 3-12 months after injury. Methods: Of 65 patients who visited a university hospital for persistent whiplash injury-induced axial neck pain sustained 3-12 months after injury (numeric rating scale score ≥3) and had received intra-articular facet joint corticosteroid injection, 40 completed the telephone interview. We divided the patients into "good response group" (≥50% pain reduction at 1 month after the injection) and "poor response group" (<50% pain reduction at 1 month after the injection). We asked participants regarding the presence and degree of neck pain, its impact on work, and the use of oral pain medication or injection treatment. Results: A follow-up at least 5 years after the injury found that the number of patients with persistent whiplash injury-related neck pain was significantly lower in the good response group than in the poor response group. The number of patients taking oral pain medications prescribed by a medical doctor or receiving injection treatments in a pain clinic or hospital for neck pain was lower in the good response group than in the poor response group. The number of patients who answered that their work was affected by neck pain was lower in the good response group than in the poor response group. Conclusion: The response to intra-articular corticosteroid injection might be helpful in determining at least 5-year outcomes of chronic whiplash injury-induced pain.

The kinematic features of hyoid bone movement during swallowing in different disease populations: A narrative review.

The anterior-superior movement of the hyoid bone plays a significant role in securing the airway and smooth passage of food through the cricopharyngeal muscle. The hyoid bone can be detected easily with instruments such as the videofluoroscopic swallow study (VFSS) and ultrasonography (US), which have made quantitative kinematic analysis possible. Dysphagia is a critical issue in different diseases, including stroke, Parkinson's disease (PD), head and neck cancer, and amyotrophic lateral sclerosis (ALS), and the data obtained on these diseases from swallowing kinematic analysis has been accumulating. In this review article, we aimed to present the distinct features of kinematic analysis of hyoid movement in stroke, PD, head and neck cancer, and ALS. We also present the possible relationship between altered hyoid kinematics and dysphagia.

Cytomegalovirus lumbosacral polyradiculitis in patients with long-term use of an oral corticosteroid: a case report.

BACKGROUND: The long-term use of an oral corticosteroid suppresses immunity. Here, we describe a case involving a patient with weakness in the bilateral lower extremities due to cytomegalovirus (CMV) lumbosacral polyradiculitis. CASE PRESENTATION: A 64-year-old man visited a university hospital for symmetric motor weakness in both lower extremities (Medical Research Council grade: 2). Symptoms started 1 month before and gradually aggravated. The patient had been taking oral prednisolone for 10 years in order to control pain in multiple joints due to seronegative rheumatoid arthritis. He also had neuropathic pain on the entire right lower extremity and voiding difficulty. Gadolinium-enhanced magnetic resonance imaging revealed enhancement along the entire lumbosacral nerve roots. In the cerebrospinal fluid analysis (CSF), elevated white blood cell (WBC) count (19 cells/µL) and protein level (142.5 mg/dL) were observed. CMV detection by polymerase chain reaction (PCR) was positive. We diagnosed the patient as having lumbosacral polyradiculitis due to CMV. Ganciclovir (250 mg twice daily) was administered intravenously. Two months after initiating Ganciclovir, in the CSF analysis, CM detection by PCR was negative, and no WBC was found. CONCLUSION: We reported a patient who had symmetric motor weakness in the bilateral lower extremities induced by CMV lumbosacral polyradiculitis. Its occurrence seems to be related to immunosuppresion due to the long-term use of an oral corticosteroid. When a patient who is taking an oral corticosteroid shows motor weakness in the bilateral lower extremities, CMV lumbosacral polyradiculitis is one of the possible disorders to be differentiated.

A multi-disciplinary rehabilitation approach for people surviving severe COVID-19-a case series and literature review.

BACKGROUND/PURPOSE: COronaVIrus Disease 2019 (COVID-19) has caused tremendous casualties and morbidities worldwide. Multisystem manifestations, including muscle weakness, dyspnea, cognitive decline, dysphagia, and dysarthria are frequently reported among critically ill patients. The resultant activity limitations and participation restrictions call for an organized and multidisciplinary approach to rehabilitation. Taiwan had a rapid surge in community infection cases from May to July 2021, and our team established a team-based approach in response to the rehabilitation needs for the in-patients, especially the critically-ill group. METHODS: We built a core treatment team and established a referral pathway for critically ill patients with COVID-19 based on a multidisciplinary approach. The care process and outcomes of a case series of patients who received in-patient rehabilitation after medical stabilization were presented. RESULTS: Our clinical care module was established according to interim World Health Organization guidance and current research and demonstrated a high degree of feasibility. Five patients with multiple impairments received in-patient rehabilitation and experienced significant functional improvement. We documented improvements in motor function, swallowing function, and activities of daily living after the rehabilitation. CONCLUSION: Our clinical experience suggests considerable benefits can be obtained from a well-organized and multidisciplinary rehabilitation approach for severe COVID-19 patients.

Ultrasonographic diagnosis and guided treatment of erector spinae aponeurosis enthesopathy.

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