Clinical Features and Voxel-Based-Symptom-Lesion Mapping of Silent Aspiration in Acute Infratentorial Stroke.

Post-stroke dysphagia (PSD) is a severe and common complication after ischemic stroke. The role of silent aspiration as an important contributing factor in the development of a dysphagia-associated complications, in particular aspiration-associated pneumonia has been insufficiently understood. The aim of this study was to investigate the characteristics and risk factors of silent aspiration in patients with acute infratentorial stroke by FEES and to identify culprit lesions in stroke patient with a high risk of silent aspiration via voxel-based-symptom-lesion mapping (VBS/ML). This study is a retrospective observational study based on a prospectively collected FEES and stroke database. Consecutive patient cases with acute ischemic infratentorial stroke and FEES examination between 2017 and 2022 were identified. Group allocation was performed based on PAS scores. Imaging analysis was performed by manual assignment and by VBS/ML. Group comparisons were performed to assess silent aspiration characteristics. Binary logistic regression analysis was performed to determine if baseline clinical, demographic, and imaging parameters were helpful in predicting silent aspiration in patients. In this study 84 patient cases with acute infratentorial stroke who underwent FEES examination were included. Patients were moderately affected at admission (mean NIH-SS score at admission 5.7 SD ± 4.7). Most lesions were found pontine. Overall 40.5% of patients suffered from silent aspiration, most frequently in case of bilateral lesions. Patients with silent aspiration had higher NIH-SS scores at admission (p < 0.05), had a more severe swallowing disorder (p < 0.05) and were 4.7 times more likely to develop post-stroke pneumonia. Patients who underwent FEES examination later than 72 h after symptom onset were significantly more likely to suffer from silent aspiration and to develop pneumonia compared to patients who underwent FEES examination within the first 72 h (p < 0.05). A binary logistic regression model identified NIH-SS at admission as a weak predictor of silent aspiration. Neither in manual assignment of the lesions to brain regions nor in voxel-wise statistic regression any specific region was useful in prediction of silent aspiration. Silent aspiration is common in patients with infratentorial stroke and contributes to the risk for pneumonia. Patients with silent aspiration are more severely affected by stroke, but cannot reliably be identified by NIH-SS at admission or lesion location. Patients suffering from acute infratentorial stroke should been screened and examined for PSD and silent aspiration.

Shedding light on the clinical recognition process of transient global amnesia.

BACKGROUND AND PURPOSE: Diagnostic uncertainty is common in the emergency evaluation of neurological conditions such as acute confusional states, particularly for non-neurologists. We aimed to investigate the clinical recognition process of transient global amnesia (TGA) before arrival at the hospital and in the emergency department (ED). METHODS: In this retrospective observational study, medical records of 365 patients with TGA were analysed concerning mode of arrival, symptoms and suspected diagnosis made by pre-hospital medical care providers and the ED neurologist. RESULTS: More than half of the 248 patients who were evaluated before arrival at the hospital (N = 157, 63.3%) received a diagnosis of suspected stroke, whereas TGA was considered in only 16 patients (6.5%), with recognition of acute amnesia in 150 patients (60.5%) and disturbed orientation in 86 patients (34.7%). Repetitive questions by the patient were noted in 28 patients (11.3%). In contrast, in 355 patients (97.3%), TGA was considered the primary diagnosis by the ED neurologist. Diagnosis in the ED was achieved by documenting ongoing impairment of episodic verbal memory (100.0%), repetitive questions as a prominent ancillary finding (95.5%) and the lack of focal neurological symptoms (100.0%) or by carefully obtaining collateral history suggestive of anterograde memory disturbance (89.9%) and/or repetitive questions (85.7%). CONCLUSION: Recognizing TGA crucially depends on identifying isolated anterograde episodic long-term memory disturbance or its observable effects such as repetitive questions and actions.

What remains after transient global amnesia (TGA)? An ultra-high field 7 T magnetic resonance imaging study of the hippocampus.

BACKGROUND AND PURPOSE: The aim was to study whether ultra-high field 7 T magnetic resonance imaging (MRI) can demonstrate chronic focal defects in the hippocampus corresponding to the former acute diffusion-weighted imaging (DWI) lesions and to assess chronic T2-hyperintense hippocampal lesion load in transient global amnesia (TGA) patients. METHODS: Follow-up of 7 T MRI of the hippocampus was performed in 13 patients with documented hippocampal DWI lesions (detected via 3 T MRI) after acute TGA. The location of the DWI lesions was transformed to 7 T T2 images after data co-registration. Additionally, the T2-hyperintense lesion load was estimated in each patient and compared with that of 13 healthy controls. RESULTS: Magnetic resonance imaging (7 T) was performed after a median of 4 months. No structural abnormality at the site of the previous TGA lesion was observed in any case. None of the controls showed DWI lesions. There was no significant difference between patients and controls concerning the number (P = 0.67) or volume (P = 0.45) of T2-hyperintense hippocampal lesions. CONCLUSIONS: Diffusion-weighted imaging lesions in patients with TGA do not provoke any visible sequelae and do not result in hippocampal cavities. The occurrence of incidental hippocampal T2 lesions after TGA is not more frequent than in controls.

Hippocampal infarction: Identification of three new types.

BACKGROUND AND PURPOSE: Hippocampal infarction (HI) is common but yet still not comprehensively studied. In the present study, we aimed to identify novel HI patterns and to describe additional ischemic lesions outside the hippocampus to draw conclusions regarding the underlying vessel occlusion. METHODS: In 222 patients (mean age 69.9 (±13.6) years; 129 (58.1%) male, 93 (41.9%) female) with HI, diffusion-weighted images were analyzed with emphasis on HI patterns and associated ischemic lesions outside the hippocampus. HI were classified as type 1 (complete), 2 (lateral), 3 (dorsal), and 4 (circumscribed). Further possible HI patterns were defined and classified as type 5 (ventral), 6 (ventrolateral), and 7 (dorsolateral). RESULTS: Unilateral HI was found in 218 (98.2%) patients. In these, type 5 and 6 were identified in 5 (2.3%) patients, and type 7 in 8 (3.7%) patients respectively. Type 1 was found in 62 (28.4%), 2 in 53 (24.3%), 3 in 57 (26.1%), and 4 in 28 (12.8%) patients. Further ischemic lesions were found in the territory of the anterior cerebral artery (3.6%), middle cerebral artery (14.9%), anterior choroidal artery (AChA) (7.2%), posterior cerebral artery (89.6%), and in the brainstem (6.3%) and cerebellum (20.3%). Type 5 and 6 were significantly associated with acute ischemic lesions in the AChA territory (6/10 (60%) vs. 11/200 (5.5%), P<0.001). CONCLUSIONS: We identified three novel HI types. Probably, type 5 and 6 can be attributed to occlusion of the AChA. Overall, these HI types are rare, possibly due to a better collateralization in the case of AChA occlusion.

Continuous magnetic resonance perfusion imaging acquisition during systemic thrombolysis in acute stroke.

BACKGROUND: Early recanalization and increase in collateral blood supply are powerful predictors of favourable outcome in acute ischaemic stroke. The factors contributing to the heterogeneous response to intravenous thrombolysis therapy in individual patients, however, are not fully understood. The on-going single-centre 'MR perfusion imaging during thrombolysis' study uses repetitive arterial spin labelling (ASL) measurements to characterize the haemodynamic processes in acute stroke during therapy. The first milestone was to develop an appropriate infrastructure for thrombolysis in the magnetic resonance imaging (MRI) scanner without time delay and ensuring optimal patient safety and care. METHODS: Between February and December 2011, 16 patients with acute neurological symptoms suggestive of hemispheric stroke within 4.5 h after symptom onset were included. In addition to clinical data, we documented the time from onset to arrival at the hospital, start and duration of MRI examination, start of thrombolytic therapy, and complications. The decision to thrombolyse was made after a routine stroke MRI protocol. During the 60-min systemic thrombolysis, repetitive ASL perfusion imaging was acquired, providing non-invasive information on cerebral perfusion. Continuous ECG monitoring, pulse oximetry, blood pressure measurements every 5 min, and short neurological assessments every 15 min were performed in every patient. RESULTS: The median initial NIHSS score of the patients presenting with a mean of 84 min after onset was 4 (range 2-18). MRI examination was initiated within a mean of 45 min after arrival at the hospital. Five patients identified as stroke mimics were not treated with recombinant tissue plasminogen activator (rt-PA), and in 1 case with basilar artery occlusion bridging therapy was performed outside the scanner. In the remaining 10 patients, rt-PA therapy was started in the scanner directly after decision making on the basis of clinical information and baseline MRI. The mean door-to-needle time was 60 min (range 44-115) including approximately 10 min needed for acquiring informed consent. While 4 patients required antihypertensive treatment, no relevant complications were encountered. CONCLUSIONS: Fast and safe medical care in patients during systemic thrombolysis in the MRI scanner is feasible. Despite the process of obtaining informed consent, with a dedicated and experienced stroke team the door-to-needle time can be kept in a range recommended by current guidelines. Continuous real-time information about the dynamics of cerebral perfusion from ASL perfusion in acute stroke patients undergoing thrombolysis may provide additional information for the understanding of the events following acute arterial obstruction and its course.

Blood-CSF-barrier dysfunction is a marker for encephalitic involvement in patients with aseptic meningitis/meningoencephalitis.

BACKGROUND: The term "aseptic meningitis" encompasses cases of meningitis with negative bacterial CSF culture, which predominantly are of viral etiology. While the clinical course is usually benign, complications such as encephalitic involvement resulting in a more severe clinical course may occur. Dysfunction of the blood-brain-barrier (BBB), which is a prerequisite for viral entry into the brain parenchyma, can be approximated using the CSF/serum albumin ratio, readily obtainable in routine CSF analysis. OBJECITVES: Analysis of CSF patterns in patients with aseptic meningitis/meningoencephalitis with a focus on BBB dysfunction as a marker for encephalitic involvement. STUDY DESIGN: Retrospective chart review of patients admitted to our hospital between 2004 and 2016 with a diagnosis of aseptic meningitis/meningoencephalitis. RESULTS: Patients with aseptic meningitis displaying clinical, MR-tomographic or electroencephalographic signs of encephalitic involvement were significantly older than patients without these features (47.4 vs. 35.5 yrs., p=0.002). In patients with meningoencephalitis, CSF analysis revealed a more severe disruption of BBB, approximated by the CSF/serum albumin ratio (p=0.002). Compromised BBB function correlated positively with length of hospitalization (p=0.007), indicative of a more severe clinical course. The number of CSF lymphocytes was found to predict the severity of the BBB disruption, which additionally was more frequently observed when herpesviridae were identified as infectious agents. CONCLUSIONS: We suggest that the CSF/serum albumin ratio as an estimate for BBB function should be attended to in the evaluation of patients with aseptic meningitis. Severe BBB dysfunction, older age and infection with herpesviridae appear to raise the risk for encephalitic involvement.

In vivo 19F-NMR study of isoflurane elimination from brain.

The time course of isoflurane elimination from rabbit brain was studied in vivo with 19F-NMR spectroscopy. Two exponential decay functions with different time constants were observed and assigned to two distinct brain compartments. Isoflurane has a 26 min time constant for one compartment (similar to a value of 25 min with halothane) but 174 min in the second one, compared with 320 min for halothane. The shorter half-life for isoflurane may be due to lower solubility of this agent in brain tissue. Comparison of isoflurane 19F chemical shifts in solvents in isolated brain lipids and in whole brain tissue indicates that the anesthetic present in the brain exists in a single environment (on the NMR time scale), which is a weighted average of both hydrophilic and hydrophobic environments.

In vivo 19F-NMR study of halothane distribution in brain.

Halothane distribution and elimination from rabbit brain was studied in vivo using 19F-NMR spectroscopy. Two exponential decay functions for the anesthetic were observed in the clearance curve. They are assigned to halothane in brain held in two distinct chemical environments characterized by different chemical shifts, and half-lives (25 and 320 min). A nonvolatile halothane metabolite with a half-life of several days was found to be present in rabbit brains. The in vivo results were corroborated by ex vivo experiments on excised brain tissue. Halothane was distributed in all of the major cell subfractions, whereas the metabolite was present predominantly in the cytoplasm.

A new airway device for small laboratory animals.

There is a need for a device for improved management of the airway of small laboratory animals during general anaesthesia. This report introduces such a device, referred to here as the airway device (AD). The AD has some similarity to the laryngeal mask airway (LMA) developed for human patients, but the mask portion of the device is specifically designed for small laboratory animals. In addition, the device has an oesophageal extension and unlike the LMA does not have a cuff associated with the mask. This report also shares experience of tests of one prototype AD with six New Zealand white rabbits. The AD was used for administering isoflurane and its effectiveness was evaluated during conditions of spontaneous and controlled intermittent positive pressure ventilation. The results provide encouragement for further development of the AD for airway management of small laboratory animals.

Elastin degradation in the aorta of Watanabe hereditary hyperlipidemic rabbits.

The Watanabe hereditary hyperlipidemic (WHHL) rabbit is an animal model that resembles humans with familial hyperlipidemia. In the thoracic aortae, there is also morphologic evidence of marked destruction of medial lamellar elastin fibers. Herein is provided the chemical evidence of elastolytic degradation. The levels of lysyl oxidase (L.Ox.), soluble elastin (SE) and insoluble elastin (IE) were estimated in thoracic aortae samples from New Zealand white (NZW) and WHHL rabbits at 6 months of age or 5 WHHL rabbits at 2.5 years of age. Enzyme-linked immunosorption assays (ELISA) were used in the L.Ox. and SE measurements. IE was measured following alkali extraction of aortae. There was a decrease in IE in thoracic aortae from Watanabe rabbits compared to NZW controls at 6 months of age (P < 0.1), and a further loss of IE in aortae from 2.5-year-old WHHL rabbits relative to the values at 6 months (P < 0.05). Average values for IE were: 130 mg/g for 6-month-old NZW, 100 mg/g for 6-month-old WHHL, and 60 mg/g for 2.5-year-old WHHL rabbits. Moreover, SE was only observed in aorta extracts from the older WHHL rabbits, a sign of elastolytic damage. There was also a five- to sixfold decrease in L.Ox. in the older vs. younger rabbits.

Watanabe hyperlipidemic rabbit as a model of aortic degeneration of the medial lamellar elastin unit.

At age 3 years, WHHL rabbits are near the end of their lifespan, frequently dying from the progression of their hyperlipidemic disease from events such as myocardial infarction. Out of a colony of 20 three-year-old WHHL rabbits raised as part of a NIH breeding project, 2 rabbits actually died of a ruptured thoracic aortic aneurysm. The need for a model to study abdominal aortic aneurysm formation led us to explore further the abdominal aortic pathology in aged WHHL rabbits. Six rabbit abdominal aortas from 3-year-old WHHL rabbits were preserved in formalin, sectioned, and stained for elastin. These were compared to the same sections of six normolipidemic age matched New Zealand white (NZW) rabbits. There was significant (P less than or equal to .001) destruction of the medial lamellar elastin unit in the aorta of the WHHL rabbits compared with the control NZW rabbits. Severe cholesterol deposits appeared to destroy the medial lamellae from the inside out. No definite aneurysm formation was seen in the abdominal aorta despite the significant changes in the medial lamellar elastin units. Thus, this model could be used to study the elastin degeneration of the media, but not necessarily abdominal aortic aneurysm formation.

The anterior cricoid split explored via the canine model, preliminary studies.

Since Cotton and Seid introduced a new surgical procedure, the anterior cricoid split in 1980, the treatment of the difficult-to-extubate infant or child has changed dramatically. The mechanics of how the procedure works are poorly understood. This study was undertaken to investigate the effects of the anterior cricoid split on the cricoid cartilage. The technique was modified so as to allow placement and maintenance of an endotracheal tube but still allow normal activity in the canine subjects. Australian Shepherd puppies were divided into 3 groups. Group 1 underwent the anterior cricoid split procedure with placement of an endotracheal tube stent, Group 2 underwent the anterior cricoid split procedure without the use of a stent, and Group 3 served as controls. All animals were sacrificed at 12 weeks of age. The results show that there was an actual gap in the cricoid cartilage in all animals that underwent the anterior cricoid split procedure. Stenting with an endotracheal tube significantly increased this gap. These results suggest that in the canine model the anterior cricoid split may be used to actually increase the size of the subglottic space.

Independent effects of denervating the cricothyroid muscle and stenting on the anterior cricoid split: canine model.

The anterior cricoid split (ACS) has gained in popularity since its introduction in 1980, for the treatment of the difficult to extubate child. The procedure allows a successful extubation and avoids a tracheotomy about 75% of the time. How the ACS allows extubation remains poorly understood. Animal research has shown that in the canine model the ACS results in a gap in the cricoid cartilage with a subjective increase in the subglottic space (Senders and Eisele, 1978). This gap in the cricoid cartilage develops whether or not an endotracheal tube stent is used. This experiment was designed to quantitatively evaluate the effect of the ACS on the subglottic space with or without the use of the stent, and to evaluate the effect of the cricothyroid muscle on the ACS procedure. The results show that the ACS does result in an increase in the subcricoid space, and that the use of an endotracheal tube stent does result in a larger increase. The cricothyroid muscle has a strong immediate effect on the gap in the cricoid cartilage, which is eliminated by sectioning the external laryngeal nerve. The long-term effects of sectioning the external laryngeal nerve on the gap in the cricoid cartilage were not conclusive.

Interrelations of organism prevalence, specimen collection method, and host age, sex, and breed among 8,354 canine urinary tract infections (1969-1995).

Selected information was compiled from canine urinalyses and urine cultures conducted between January 1969 and December 1995. Eight thousand three hundred fifty-four microbial isolates (bacteria and fungi) included 4,873 isolates from females and 3,481 from males. Ten bacterial genera accounted for 96.3% of the urinary isolates, including Escherichia coli (44.1%), Staphylococcus spp. (11.6%), Proteus spp. (9.3%), Klebsiella spp. (9.1%), Enterococcus spp. (8.0%), and Streptococcus spp. (5.4%) as the 6 most common isolates in both genders of dogs. Among these 6 genera, female dogs were generally predisposed over males, although males had more urinary tract infections (UTIs) caused by Klebsiella spp. Distributions of ages at UTI diagnosis tended to be similar between genders. Infection with a single microbial species was responsible for >72% of UTIs in both genders. Among females, 40 breeds and a mixed-breed group represented 90.2% of all positive urine cultures, 88.4% of the individual dogs with UTIs. and 88.2% of the microbial isolations. Among males, these same 41 breed groups represented 87.9% of all positive urine cultures, 87.6% of the individual dogs, and 88.2% of the microbial isolations.

Evaluation for malignant hyperthermia susceptibility in black-tailed deer.

To investigate a possible link of malignant hyperthermia to capture myopathy, between June 1990 and July 1993 we anesthetized four black-tailed deer (Odocoileus hemionus columbianus) and challenged them with halothane and succinylcholine. Halothane had no significant effect on oxygen consumption. Succinylcholine significantly (P < 0.05) increased cardiac output (mean +/- SD), from 2.94 +/- 1.05 l/min to 5.26 +/- 1.79 l/min, and oxygen consumption, from 5.5 +/- 2.1 ml/kg/min to 10.1 +/- 2.9 ml/kg/min. Muscle biopsy specimens tested for malignant hyperthermia susceptibility responded normally to halothane and caffeine. We conclude that these deer did not experience malignant hyperthermia; suggesting no link to capture myopathy.

A practical dog bed for environmental enrichment for geriatric beagles, with applications for puppies and other small dogs.

A group of 30 older beagle dogs was acquired for aging studies. The dogs were initially housed in kennel runs equipped with elevated benches, but it became apparent that some of the oldest animals had difficulties jumping down from them. To improve animal safety and comfort, practical dog beds were made out of the ends of clean high-density polyethylene barrels. Synthetic fleece bed liners were used for dogs that did not chew them or remove them from the beds. Nine of the beagles regularly were observed to use the beds. We also have found that this easily fashioned dog bed is a useful kennel resting place option for puppies and other small dogs.

Design and use of a protective jacket to prevent self-inflicted injury following cervical laminoplasty in the goat (Capra hircus).

A group of dairy goats underwent cervical laminoplasty procedures as part of a biomechanics project. Although most animals had minimal incisional complications, several developed excoriations exacerbated by scratching at the incision site 6 to 8 weeks after the surgery. Local and systemic treatment was instituted as indicated. Bandages were inadequate to protect the neck from self-trauma, and the potential existed for serious injury to or infection of the old surgical site. We designed and made custom padded jackets for these animals. Treatment continued. While allowing the animals to exercise their scratching behavior, the jackets protected the traumatized area until healing was complete and the pruritus resolved. This jacket or modifications of it may be useful in other goat, sheep, or calf projects in which protection of the neck, shoulders, and thorax is needed.

Reduced diffusion in a subset of acute MS lesions: a serial multiparametric MRI study.

BACKGROUND AND PURPOSE: MRI studies have focused on newly developing MS lesions to characterize the early pathology of the disease. DWI is highly sensitive to acute and chronic tissue changes in MS. We characterized the development of acute MS lesions by using DWI in a multiparametric MRI protocol. MATERIALS AND METHODS: Seventy-two consecutive patients presenting with a new symptom with definite MS or a CIS suggestive of central nervous system demyelination were screened with MRI. Patients who showed an acute MRI lesion with a reduction of ADC were studied with serial MRI for up to 4 months after presentation. RESULTS: Ten of 72 screened patients who showed a lesion with a reduced ADC were each examined 4-7 times, resulting in 52 examinations in total. We identified a characteristic sequence of signal-intensity changes: 1) days 0-7: slight T2 hyperintensity and prominent ADC reduction (maximum, -66%), faint or no enhancement on postcontrast T1-weighted images; 2) days 7-10: prominent T2 hyperintensity and contrast enhancement, ADC normalization/pseudonormalization; 3) up to 4 weeks: elevated ADC values, prominent enhancement on postcontrast images; 4) after 4 weeks: partial reversibility of T2 hyperintensity, ADC elevation, and resolution of contrast enhancement. CONCLUSIONS: In a subgroup of patients with MS presenting soon after new symptom onset, a transient reduction of the ADC delineated a short and very early phase of MS lesion evolution. Subsequent pseudonormalization of the ADC occurred along with signs of the development of vasogenic edema.