Implantable Cardiac Defibrillator Lead Infective Endocarditis Due to Rothia Specie: A Rare Case in An Immunocompetent Man.

Background: Rothia species are known to cause dental caries and periodontal disease, and infrequently cause native or prosthetic valve endocarditis mostly in immunocompromised persons. With an increasing use of implantable cardiac devices, early clinical suspicion and a rapid diagnosis of endocarditis is essential for optimal treatment to reduce complications and mortality. Bacteremic infection with Rothia dentocariosa in immunocompetent persons is uncommon. Pacemaker lead-related endocarditis caused by Rothia spp. is rare and management guidelines are not defined. Case Presentation: We report a rare case of implantable cardiac defibrillator (ICD) lead endocarditis in an immunocompetent patient that was caused by Rothia dentocariosa. Conclusions: Clinicians should be aware of this rare cause of CIED lead infections and should be acquainted with the optimal strategies of prompt antibiotic therapy and removal of the infected device/leads.

Racial differences in cardiopulmonary outcomes of hospitalized COVID-19 patients with acute kidney injury.

In-hospital acute kidney injury (IH-AKI) has been reported in a significant proportion of patients with COVID-19 and is associated with increased disease burden and poor outcomes. However, the mechanisms of injury are not fully understood. We sought to determine the significance of race on cardiopulmonary outcomes and in-hospital mortality of hospitalized COVID-19 patients with AKI. We conducted a retrospective cohort study of consecutive patients hospitalized in Grady Health System in Atlanta, Georgia between February and July 2020, who tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on qualitative polymerase-chain-reaction assay. We evaluated the primary composite outcome of in-hospital cardiac events, and mortality in blacks with AKI versus non-blacks with AKI. In a subgroup analysis, we evaluated the impact of AKI in all blacks and in all non-blacks. Of 293 patients, effective sample size was 267 after all exclusion criteria were applied. The mean age was 61.4 ± 16.7, 39% were female, and 75 (28.1%) had IH-AKI. In multivariable analyses, blacks with IH-AKI were not more likely to have in-hospital cardiac events (aOR 0.3, 95% Confidence interval (CI) 0.04-1.86, p = 0.18), require ICU stay (aOR 0.80, 95% CI 0.20-3.25, p = 0.75), acute respiratory distress syndrome (aOR 0.77, 95% CI 0.16-3.65, p = 0.74), require mechanical ventilation (aOR 0.51, 95% CI 0.12-2.10, p = 0.35), and in-hospital mortality (aOR 1.40, 95% CI 0.26-7.50, p = 0.70) when compared to non-blacks with IH-AKI. Regardless of race, the presence of AKI was associated with worse outcomes. Black race is not associated with higher risk of in-hospital cardiac events and mortality in hospitalized COVID-19 patients who develop AKI. However, blacks with IH-AKI are more likely to have ARDS or die from any cause when compared to blacks without IH-AKI.

Detection of infectious spleen and kidney necrosis virus (ISKNV) and turbot reddish body iridovirus (TRBIV) from archival ornamental fish samples.

Although infections caused by megalocytiviruses have been reported from a wide range of finfish species for several decades, molecular characterisation of the viruses involved has been undertaken only on more recent cases. Sequence analysis of the major capsid protein and adenosine triphosphatase genes is reported here from formalin-fixed, paraffin-embedded material from 2 archival ornamental fish cases from 1986 and 1988 in conjunction with data for a range of genes from fresh frozen tissues from 5 cases obtained from 1991 through to 2010. Turbot reddish body iridovirus (TRBIV) genotype megalocytiviruses, previously not documented in ornamental fish, were detected in samples from 1986, 1988 and 1991. In contrast, megalocytiviruses from 1996 onwards, including those characterised from 2002, 2006 and 2010 in this study, were almost indistinguishable from infectious spleen and kidney necrosis virus (ISKNV). Three of the species infected with TRBIV-like megalocytiviruses from 1986 to 1991, viz. dwarf gourami Trichogaster lalius (formerly Colisa lalia), freshwater angelfish Pterophyllum scalare and oscar Astronotus ocellatus, were infected with ISKNV genotype megalocytiviruses from 2002 to 2010. The detection of a TRBIV genotype isolate in ornamental fish from 1986 represents the index case, confirmed by molecular sequence data, for the genus Megalocytivirus.

Process of formulating USDA's Expanded Flavonoid Database for the Assessment of Dietary intakes: a new tool for epidemiological research.

The scientific community continues to be interested in potential links between flavonoid intakes and beneficial health effects associated with certain chronic diseases such as CVD, some cancers and type 2 diabetes. Three separate flavonoid databases (Flavonoids, Isoflavones and Proanthocyanidins) developed by the USDA Agricultural Research Service since 1999 with frequent updates have been used to estimate dietary flavonoid intakes, and investigate their health effects. However, each of these databases contains only a limited number of foods. The USDA has constructed a new Expanded Flavonoids Database for approximately 2900 commonly consumed foods, using analytical values from their existing flavonoid databases (Flavonoid Release 3.1 and Isoflavone Release 2.0) as the foundation to calculate values for all the twenty-nine flavonoid compounds included in these two databases. Thus, the new database provides full flavonoid profiles for twenty-nine predominant dietary flavonoid compounds for every food in the database. Original analytical values in Flavonoid Release 3.1 and Isoflavone Release 2.0 for corresponding foods were retained in the newly constructed database. Proanthocyanidins are not included in the expanded database. The process of formulating the new database includes various calculation techniques. This article describes the process of populating values for the twenty-nine flavonoid compounds for every food in the dataset, along with challenges encountered and resolutions suggested. The new expanded flavonoid database released on the Nutrient Data Laboratory's website would provide uniformity in estimations of flavonoid content in foods and will be a valuable tool for epidemiological studies to assess dietary intakes.

Treatment of traumatic acute posterior fossa subdural hematoma: report of four cases with systematic review and management algorithm.

BACKGROUND: Traumatic posterior fossa subdural hematomas (SDHs) are rare lesions. Despite improvements in intensive care and surgical management of traumatic brain injuries over the last decades, the outcome for posterior fossa subdural hematomas remains poor. METHODS: We conduct a retrospective study over a 2-year period of patients sustaining traumatic brain injury and posterior fossa SDH. Additionally, a systematic review of case series published to date was performed. RESULTS: The incidence of posterior fossa SDH was 0,01% (4/326). All patients in this current series had poor prognosis. Three out of four exhibited ischemic/edema lesions in postoperative CT scans leading to fourth ventricle effacement and persistent brainstem compression. Our literature review retrieved 57 patients from only seven case series. Unfavorable outcomes were seen in 63% of patients. CONCLUSIONS: Our data and data from the literature do not provide sufficient evidence to establish an optimal treatment strategy for posterior fossa SDH. However, based on lessons learned with these four cases, together with results from review of the literature, we propose an algorithm for the management of this rare condition.

An Expanded Approach to the Ascertainment of Children and Youth With Special Health Care Needs.

OBJECTIVE: To describe the prevalence, characteristics, and health-related outcomes of children with diagnosed health conditions and functional difficulties who do not meet criteria for having a special health care need based on the traditional scoring of the Children with Special Health Care Needs (CSHCN) Screener. METHODS: Data come from the 2016 to 2021 National Survey of Children's Health (n = 225 443). Child characteristics and health-related outcomes were compared among 4 mutually exclusive groups defined by CSHCN Screener criteria and the presence of both conditions and difficulties. RESULTS: Among children who do not qualify as children and youth with special health care needs (CYSHCN) on the CSHCN Screener, 6.8% had ≥1 condition and ≥1 difficulty. These children were more likely than CYSHCN to be younger, female, Hispanic, uninsured, privately insured, living in a household with low educational attainment, have families with more children and a primary household language other than English. After adjustment, non-CYSHCN with ≥1 conditions and ≥1 difficulty were less likely than CYSHCN, but significantly more likely than other non-CYSHCN, to have ≥2 emergency department visits, have unmet health care needs, not meet flourishing criteria, live in families that experienced child health-related employment impacts and frustration accessing services. Including these children in the calculation of CYSHCN prevalence increases the national estimate from 19.1% to 24.6%. CONCLUSIONS: Approximately 4 million children have both a diagnosed health condition and functional difficulties but are not identified as CYSHCN. An expanded approach to identify CYSHCN may better align program and policy with population needs.

Spontaneous Behavioural Recovery Following Stroke Relates to the Integrity of Parietal and Temporal Regions.

Stroke is a devastating disease that results in neurological deficits and represents a leading cause of death and disability worldwide. Following a stroke, there is a degree of spontaneous recovery of function, the neural basis of which is of great interest among clinicians in their efforts to reduce disability following stroke and enhance rehabilitation. Conventionally, work on spontaneous recovery has tended to focus on the neural reorganization of motor cortical regions, with comparably little attention being paid to changes in non-motor regions and how these relate to recovery. Here we show, using structural neuroimaging in a macaque stroke model (N = 31) and by exploiting individual differences in spontaneous behavioural recovery, that the preservation of regions in the parietal and temporal cortices predict animal recovery. To characterize recovery, we performed a clustering analysis using Non-Human Primate Stroke Scale (NHPSS) scores and identified a good versus poor recovery group. By comparing the preservation of brain volumes in the two groups, we found that brain areas in integrity of brain areas in parietal, temporal and somatosensory cortex were associated with better recovery. In addition, a decoding approach performed across all subjects revealed that the preservation of specific brain regions in the parietal, somatosensory and medial frontal cortex predicted recovery. Together, these findings highlight the importance of parietal and temporal regions in spontaneous behavioural recovery.

Fatigue in adult patients with primary immune thrombocytopenia.

BACKGROUND: Patients with primary immune thrombocytopenia (ITP) commonly describe symptoms of fatigue. However, hematologists rarely consider fatigue a manifestation of ITP. OBJECTIVES: To document the prevalence of fatigue among patients with ITP and to determine the patient characteristics that are associated with fatigue. Using a cross-sectional design, we surveyed 1871 members of the UK ITP Support Association [585 (31%) responded], and 93 patients enrolled in the Oklahoma (US) ITP Registry [68 (73%) responded] with questions about their ITP and with validated symptom assessment scales for fatigue, daytime sleepiness, and orthostatic symptoms. RESULTS: The prevalence of fatigue among both UK (39%) and US (22%) patients was significantly greater than expected compared with normal subjects (P<0.0001 and P<0.0001 respectively). In univariate analysis of the combined cohorts, fatigue was associated with a platelet count <100000/µL, treatment with steroids, bleeding symptoms, presence of other medical conditions, daytime sleepiness, and orthostatic symptoms. Fatigue was not associated with age, gender, duration of ITP, or splenectomy status. Multivariate analysis of the combined cohorts was stratified for the presence or absence of bleeding symptoms. Among 107 patients with bleeding symptoms, fatigue was independently associated with a platelet count <100000/µL and female gender. Among 491 patients without bleeding symptoms, fatigue was independently associated with a platelet count <30000/µL, presence of other medical conditions, daytime sleepiness, and orthostatic symptoms. CONCLUSIONS: Fatigue is a common symptom among patients with ITP. These data provide the basis for future studies to define the clinical importance of fatigue in ITP.

Dexmedetomidine controls agitation and facilitates reliable, serial neurological examinations in a non-intubated patient with traumatic brain injury.

INTRODUCTION: We report the effective use of dexmedetomidine in the treatment of a patient with a history of chronic alcohol abuse and an acute traumatic brain injury who developed agitation that was unresolved if from traumatic brain injury, or alcohol withdrawal or the combination of both. Treatment with benzodiazepines failed; lorazepam therapy obscured our ability to do reliable neurological testing to follow his brain injury and nearly resulted in intubation of the patient secondary to respiratory suppression. Upon admission to hospital, the patient was first treated with intermittent, prophylactic doses of lorazepam for potential alcohol withdrawal based upon our institution's standard of care. His neurological examinations including a motor score of 6 (obeying commands) on his Glasgow Coma Scale testing, laboratory studies, and repeat CT head imaging remained stable. For lack of published literature in diagnosing symptoms of patients with a history of both alcohol withdrawal and traumatic brain injury, a diagnosis of agitation secondary to presumed alcohol withdrawal was made when the patient developed acute onset of tachycardia, confusion, and extreme anxiety with tremor and attempts to climb out of bed requiring him to be restrained. Additional lorazepam doses were administered following a hospital-approved protocol for titration of benzodiazepine therapy for alcohol withdrawal. The patient's mental status and respiratory function deteriorated with the frequent lorazepam dosing needed to control his agitation. Dexmedetomidine IV infusion at a rate of 0.5 mcg/kg/h was then administered and was titrated ultimately to 1.5 mcg/kg/h. After 8 days of therapy with dexmedetomidine, the patient was transferred from the ICU to a step-down unit with an intact neurological examination and no evidence of alcohol withdrawal. Airway intubation was avoided during the patient's entire hospitalization. This case report highlights the intricate balance between the side effects of benzodiazepine sedation for treatment of agitation and the difficulties of monitoring the neurological status of non-intubated patients with traumatic brain injury. CONCLUSION: Given the large numbers of alcohol-dependent patients who suffer a traumatic brain injury and subsequently develop agitation and alcohol withdrawal in hospital, dexmedetomidine offers a novel strategy to facilitate sedation without neurological or respiratory depression. As this case report demonstrates, dexmedetomidine is an emerging treatment option for agitation in patients who require reliable, serial neurological testing to monitor the course of their traumatic brain injury.

Acute on chronic severe aortic insufficiency due to rheumatoid arthritis-associated valvulitis.

Rheumatoid Arthritis associated valvular heart disease (RA-VHD) may occur in patients in varying degrees of severity. Aortic valve involvement leading to severe symptomatic aortic insufficiency is a rare complication of rheumatoid arthritis. This entity has not been well characterized and its clinical predictors are undefined. The pathology of RA-VHD can extend from benign nodular development to acute valvulitis with late-stage leaflet fibrosis and severe valvular regurgitation. In this report, we describe a rare case of acute heart failure (AHF) resulting from severe aortic valve destruction and insufficiency due to persistent chronic inflammation in a patient with long-standing RA. Persistent systemic inflammation of RA involved the aortic valve causing nodular thickening and leaflet destruction. Our patient had compensated chronic heart failure due to progressive aortic insufficiency resulting from gradual leaflet destruction. However, she suddenly developed AHF requiring valve replacement. Her clinical presentation, gross and histological images suggest an acute/subacute disruption of the friable aortic leaflets that resulted in AHF.

Left main stenting with stent dislodgement and entrapment in the common femoral artery: a successful transcatheter stent retrieval.

Proximal left main stenting in symptomatic patients with flow-limiting stenosis is an alternative revascularization strategy in individuals with low syntax score and high operative risk. Stent dislodgement is associated with adverse cardiovascular events and retrieval of fully deployed stents is generally prohibited as it increases the risk of severe complications. Stent dislodgement and entrapment in the femoral vascular system occur infrequently during percutaneous coronary interventions. In this report, we illustrate a prompt and safe transcatheter technique to successfully retrieve an expanded and dislodged coronary stent entrapped in the common femoral artery without need for a more invasive surgical approach.

Food Sources of Key Nutrients, Meal and Dietary Patterns among Children Aged 4-13 Years in Ibadan, Nigeria: Findings from the 2019 Kids Nutrition and Health Study.

This study examined the contribution of food to nutrient intake, meal and dietary patterns among children aged 4-8 and 9-13 years in the city of Ibadan, Nigeria. Multi-pass 24-hour dietary recalls were used to assess intakes. Prudent and traditional Southwestern Nigerian dietary patterns were identified among children. The top foods and beverages were defined by frequency and amount consumed. Meal patterns were described by the eating occasions, while cluster analysis probed dietary patterns. About 88% of children had at least three meals including breakfast (95%), lunch (85%), dinner (92%) and midmorning meals (48%), while about 60% ate snacks at least once daily. Sources of energy and key nutrients were limited (yam, cassava, rice, maize, bread and beans/peas/legumes). The amount consumed per consumer of cassava products (192.2, 256.0 g), yam (169.7, 256.0 g), legumes (115.3, 150.7 g), corn/maize (160.4, 195.2), and rice (138.4, 182.3 g) were high, while beef (15.2, 17.9 g), eggs (50.6, 49.2 g), fish (27.5, 30.6 g), milk (24.2, 27.0 g) and nuts and seeds (18.2, 19.7 g) were low for children ages 4-8 and 9-13 years, respectively. In conclusion, while the frequency of meals suggests a healthy pattern, the top foods could not provide adequate nutrient (especially micronutrient) intake, which is key to the development of the target population.

Pre-existing cardiovascular disease, acute kidney injury, and cardiovascular outcomes in hospitalized blacks with COVID-19 infection.

BACKGROUND: The Corona Virus 19 (COVID-19) infection is associated with worse outcomes in blacks, although the mechanisms are unclear. We sought to determine the significance of black race, pre-existing cardiovascular disease (pCVD), and acute kidney injury (AKI) on cardiopulmonary outcomes and in-hospital mortality of COVID-19 patients. METHODS: We conducted a retrospective cohort study of blacks with/without pCVD and with/without in-hospital AKI, hospitalized within Grady Memorial Hospital in Georgia between February and July 2020, who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on qualitative polymerase-chain-reaction assay. The primary outcome was a composite of in-hospital cardiac events. RESULTS: Of the 293 patients hospitalized with COVID-19 in this study, 71 were excluded from the primary analysis (for race/ethnicity other than black non-Hispanic). Of the 222 hospitalized COVID-19 patients included in our analyses, 41.4% were female, 78.8% had pCVD, and 30.6% developed AKI during the admission. In multivariable analyses, pCVD (OR 4.7, 95% CI 1.5-14.8, P=0.008) and AKI (OR 2.7, 95% CI 1.3-5.5, P=0.006) were associated with increased odds of in-hospital cardiac events. AKI was associated with increased odds of in-hospital mortality (OR 8.9, 95% CI 3.3-23.9, P<0.0001). The presence of AKI was associated with increased odds of ICU stay, mechanical ventilation, and acute respiratory distress syndrome (ARDS). CONCLUSION: pCVD and AKI were associated with higher risk of in-hospital cardiac events, and AKI was associated with a higher risk of in-hospital mortality in blacks.

Hemicraniectomy: a new model for human electrophysiology with high spatio-temporal resolution.

Human electrophysiological research is generally restricted to scalp EEG, magneto-encephalography, and intracranial electrophysiology. Here we examine a unique patient cohort that has undergone decompressive hemicraniectomy, a surgical procedure wherein a portion of the calvaria is removed for several months during which time the scalp overlies the brain without intervening bone. We quantify the differences in signals between electrodes over areas with no underlying skull and scalp EEG electrodes over the intact skull in the same subjects. Signals over the hemicraniectomy have enhanced amplitude and greater task-related power at higher frequencies (60-115 Hz) compared with signals over skull. We also provide evidence of a metric for trial-by-trial EMG/EEG coupling that is effective over the hemicraniectomy but not intact skull at frequencies >60 Hz. Taken together, these results provide evidence that the hemicraniectomy model provides a means for studying neural dynamics in humans with enhanced spatial and temporal resolution.

Benign anterior temporal epidural hematoma: indolent lesion with a characteristic CT imaging appearance after blunt head trauma.

PURPOSE: To study the incidence, pathogenesis, imaging characteristics, and clinical importance of a unique subtype of epidural hematoma (EDH) associated with blunt head trauma. MATERIALS AND METHODS: This study was reviewed and approved by the hospital's Institutional Review Board and was compliant with HIPAA. Informed consent was waived. The investigation was a retrospective study of 200 patients with acute supratentorial EDH, defined as a biconvex, high-attenuating, extraaxial hematoma. A subgroup of 21 patients in whom the EDH was located at the anterior aspect of the middle cranial fossa was defined. Computed tomographic images and inpatient medical records of these 21 patients were evaluated for imaging characteristics of the EDH, presence or absence of associated fracture, presence or absence of midline shift and/or mass effect, additional intracranial injury, and hospital clinical course. RESULTS: Twenty-one (10.5%) of 200 traumatic EDHs localized to the anterior middle cranial fossa. All of these 21 anterior temporal EDHs were juxtaposed to the sphenoparietal sinus, and all but one were limited laterally by the sphenotemporal suture and medially by the orbital fissure; none extended above the lesser sphenoid wing. Maximum thickness was less than 1 cm in 13 (62%) of 21 and less than 2 cm in 20 (95%) of 21 patients. Isolated fractures of the greater sphenoid wing and ipsilateral zygomaticomaxillary fractures were present in 12 (57%) of 21 and nine (43%) of 21 patients, respectively. Concomitant intracranial injury was identified in 15 (71%) of 21 patients. Twenty (95%) of 21 lesions were present at the admission study, and all 21 were stable or smaller at follow-up imaging. No patient required neurosurgical intervention of their anterior temporal EDH. CONCLUSION: Acute EDHs isolated to the anterior aspect of the middle cranial fossa constitute a subgroup of traumatic EDHs with a benign natural history. It is postulated that they arise from venous bleeding due to disruption of the sphenoparietal sinus.

Survival with good outcome after cerebral herniation and Duret hemorrhage caused by traumatic brain injury.

Brainstem hemorrhage can occur as a primary or secondary event in traumatic brain injury (TBI). Secondary brainstem hemorrhage that evolves from raised intracranial pressure and transtentorial herniation is referred to as Duret hemorrhage. Duret hemorrhage following TBI has been considered an irreversible and terminal event. The authors report on the case of a young adult patient with TBI who presented with a low Glasgow Coma Scale score and advanced signs of cerebral herniation. She underwent an urgent decompressive hemicraniectomy for evacuation of an acute epidural hematoma and developed a Duret hemorrhage postoperatively. In accordance with the family's wishes, aggressive TBI monitoring and treatment in the intensive care unit was continued even though the anticipated outcome was poor. After a lengthy hospital course, the patient improved dramatically and was discharged ambulatory, with good cognitive functioning and a Glasgow Outcome Scale score of 4. Duret hemorrhage secondary to raised intracranial pressure is not always a terminal event, and by itself should not trigger a decision to withdraw care. Aggressive intracranial monitoring and treatment of a Duret hemorrhage arising secondary to cerebral herniation may enable a good recovery in selected patients after severe TBI.

Complications of decompressive craniectomy for traumatic brain injury.

Decompressive craniectomy is widely used to treat intracranial hypertension following traumatic brain injury (TBI). Two randomized trials are currently underway to further evaluate the effectiveness of decompressive craniectomy for TBI. Complications of this procedure have major ramifications on the risk-benefit balance in decision-making during evaluation of potential surgical candidates. To further evaluate the complications of decompressive craniectomy, a review of the literature was performed following a detailed search of PubMed between 1980 and 2009. The author restricted her study to literature pertaining to decompressive craniectomy for patients with TBI. An understanding of the pathophysiological events that accompany removal of a large piece of skull bone provides a foundation for understanding many of the complications associated with decompressive craniectomy. The author determined that decompressive craniectomy is not a simple, straightforward operation without adverse effects. Rather, numerous complications may arise, and they do so in a sequential fashion at specific time points following surgical decompression. Expansion of contusions, new subdural and epidural hematomas contralateral to the decompressed hemisphere, and external cerebral herniation typify the early perioperative complications of decompressive craniectomy for TBI. Within the 1st week following decompression, CSF circulation derangements manifest commonly as subdural hygromas. Paradoxical herniation following lumbar puncture in the setting of a large skull defect is a rare, potentially fatal complication that can be prevented and treated if recognized early. During the later phases of recovery, patients may develop a new cognitive, neurological, or psychological deficit termed syndrome of the trephined. In the longer term, a persistent vegetative state is the most devastating of outcomes of decompressive craniectomy. The risk of complications following decompressive craniectomy is weighed against the life-threatening circumstances under which this surgery is performed. Ongoing trials will define whether this balance supports surgical decompression as a first-line treatment for TBI.

Reversible monoparesis following decompressive hemicraniectomy for traumatic brain injury.

OBJECT: The "syndrome of the trephined" is an uncommon and poorly understood disorder of delayed neurological deficit following craniectomy. From the authors' extensive experience with decompressive hemicraniectomy for traumatic brain injury (TBI), they have encountered a number of patients who developed delayed motor deficits, also called "motor trephine syndrome," and reversal of the weakness following cranioplasty repair. The authors set out to study motor function systematically in this patient population to define the incidence, contributing factors, and outcome of patients with motor trephine syndrome. METHODS: The authors evaluated patient demographics, injury characteristics, detailed motor examinations, and CT scans in 38 patients with long-term follow-up after decompressive hemicraniectomy for TBI. RESULTS: Ten patients (26%) experienced delayed contralateral upper-extremity weakness, beginning 4.9 +/- 0.4 months (mean +/- standard error) after decompressive hemicraniectomy. Motor deficits improved markedly within 72 hours of cranioplasty repair, and all patients recovered full motor function. The CT perfusion scans, performed in 2 patients, demonstrated improvements in cerebral blood flow commensurate with resolution of cerebrospinal fluid flow disturbances on CT scanning and return of motor strength. Comparisons between 10 patients with and 20 patients (53%) without delayed motor deficits identified 3 factors--ipsilateral contusions, abnormal cerebrospinal fluid circulation, and longer intervals to cranioplasty repair--to be strongly associated with delayed, reversible monoparesis following decompressive hemicraniectomy. CONCLUSIONS: Delayed, reversible monoparesis, also called motor trephine syndrome, is common following decompressive hemicraniectomy for TBI. The results of this study suggest that close follow-up of motor strength with early cranioplasty repair may prevent delayed motor complications of decompressive hemicraniectomy.

Motor trephine syndrome: a mechanistic hypothesis.

BACKGROUND: In our neurotrauma practice, "motor trephine syndrome" was defined as a contralateral monoparesis that developed as a delayed and reversible complication in patients treated with decompressive hemicraniectomy for traumatic brain injury (TBI). The goal of this study was to define causal factors associated with this syndrome. METHODS: We retrospectively reviewed clinical records and imaging studies of all patients undergoing decompressive hemicraniectomy followed by cranioplasty repair in our comprehensive database of TBI patients. Detailed analysis of motor function from the time of injury to 6 months following cranioplasty repair identified three patterns of motor recovery. RESULTS: Blossoming of contusions, CSF circulation dysfunction, and longer times to cranioplasty repair were strongly associated with "motor trephine syndrome". We hypothesize that "motor trephine syndrome" arises from decompensated CSF flow with transgression of CSF fluid and edema into brain parenchyma, together with associated decrements in cerebral blood flow. CONCLUSION: Prior contusion injury, decreased skull resistance with large hemispheric decompressions, and longer intervals to cranioplasty repair facilitate transparenchymal flow of CSF and edema. "Motor trephine syndrome" is rapidly reversible following cranioplasty repair. CSF and edema fluid changes within the parenchyma and CBF normalize, coincident with improvements in the patient's motor function, upon replacement of the bone.