Alterações cardiorrespiratórias em indivíduos hemiparéticos crônicos pós-acidente vascular cerebral / Cardiorespiratory changes in chronic post-stroke hemiparetic patients

Objetivo: Analisar a função cardiorrespiratória em pacientes he- miparéticos crônicos pós-acidente vascular cerebral. Métodos: Estudo retrospectivo, por meio da análise de dados de prontuários de pacientes submetidos ao teste de caminhada de 6 minutos e manovacuometria em uma clínica de fisioterapia de um centro universitário. Foram analisados os dados de sete prontuários. Re- sultados: A média de metros percorridos pelos participantes no teste de caminhada de 6 minutos foi de 199,5. Os valores percentuais da manovacuometria foram de -41,34 na pressão inspiratória máxima e de 57,85 na pressão expiratória máxima. Conclusão: Os dados desta pesquisa sugerem que indivíduos hemiparéticos crônicos apresentam fadiga respiratória e muscular, diminuição da capacidade funcional durante a marcha e fraqueza dos músculos respiratórios.

Objective: To analyze the cardiorespiratory function in chronic post-stroke hemiparetic patients. Methods: This is a retrospective study, through data analysis of medical records from patients who underwent the 6-minute walk test and manovacuometry, in a physical therapy clinic of a university center. Results: The mean number of meters walked by participants in the 6-minut walk test was 199.5 meters. The percentage values of manovacuometry were -41,34 in the maximun inspiratory pressure and 57.85 in the maximun expiratory pressure. Conclusion: The data from this survey suggest that chronic hemiparetic individuals have respiratory and muscle fatigue, decreased functional capacity during gait, and respiratory muscle weakness.

Incidence of hemi-diaphragmatic paresis after ultrasound-guided intermediate cervical plexus block: a prospective observational study.

PURPOSE: An intermediate cervical plexus block (CPB) targets the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. The phrenic nerve descends obliquely on the surface of the anterior scalene muscle beneath the prevertebral fascia after originating from the C3-C5 ventral rami. Therefore, the phrenic nerve can be affected by a local anesthetic during an intermediate CPB, depending on the permeability characteristics of the prevertebral fascia. This study investigated whether an intermediate CPB affects the phrenic nerve, inducing hemidiaphragmatic paresis. METHODS: In this prospective observational study, 20 patients undergoing single-incision transaxillary robot-assisted right thyroidectomy were enrolled. The intermediate CPB (0.25% ropivacaine 0.2 ml/kg) was performed at the C4-5 intervertebral level carefully, without penetrating the prevertebral fascia, before the patient emerged from general anesthesia. Diaphragmatic motions of the block side were measured by M-mode ultrasonography at three time points: before anesthesia (baseline) and at 30 and 60 min after the intermediate CPB. Hemidiaphragmatic paresis was divided into three grades, depending on the percentage of diaphragm movement compared to the baseline: none (> 75%), partial paresis (25-75%), and complete paresis (< 25%). RESULTS: No patient showed any partial or complete ipsilateral hemidiaphragmatic paresis within 60 min after the intermediate CPB. CONCLUSION: Intermediate CPB using 0.2 ml/kg of 0.25% ropivacaine at the C4-5 intervertebral level did not cause ipsilateral hemidiaphragmatic paresis. This may imply that the effect of the intermediate CPB on the phrenic nerve is not significant.

Transient episodes of hemiparesis in Sturge Weber Syndrome - Causes, incidence and recovery.

INTRODUCTION: Sturge Weber Syndrome (SWS) arises from a sporadic condition secondary to a post zygotic mutation in the GNAQ gene, manifested in the majority of cases by capillary malformation of the skin. Children present with seizures, acquired hemiparesis, transient hemiparesis and intellectual disabilities. This project aimed to establish incidence of transient episodes, their recovery time if full recovery was achieved, and events associated with the transient episode. METHODS: This was a retrospective cohort study, approved for clinical audit (Institution number 2182). Children with a diagnosis of SWS seen in a tertiary multidisciplinary clinic from September 2013 to September 2016 were included in the analysis. Data was collated from clinical notes. SPSS 21 was used for analysis. RESULTS: A total of 102 patients had a diagnosed of SWS, the mean age was 10.86 years (range 2-22years). 47/102 participants with SWS had permanent hemiparesis. 32/102 presented with transient episodes. All children with transient hemiparesis had epilepsy. Median recovery time to previous function, following a transient episode was 24 h (range 1 minute-4392 h). All participants fully recovered from the transient episode within a 6 months' time frame. The factors associated with transient episodes were seizures, or a blow to the head. CONCLUSIONS: To our knowledge this is the largest cohort of children with SWS analysed to describe occurrence, association and recovery time of transient hemiparesis. The findings informed service development including change in method to record details of transient episodes. Further information provided to other health professionals will be reviewed.

Neurophysiological Monitoring During Arteriovenous Malformation Embolization.

BACKGROUND: Neurophysiological monitoring (NPM) is frequently performed during arteriovenous malformation (AVM) embolization. However, the ability of NPM to predict neurological deficits or improve surgical decision making in this setting has not been studied. OBJECTIVE: To review our use of NPM during AVM embolization to better define its utility. METHODS: We retrospectively examined AVM embolization cases from 2004 to 2017. We recorded patient and AVM characteristics as well as outcomes. We then reviewed NPM results from each case, including somatosensory evoked potentials and electroencephalogram. Our primary outcome was postoperative neurological deficit, and secondary outcomes were discharge and 30-d modified Rankin Score (mRS). RESULTS: There were 173 embolizations in 74 patients. Mean patient age was 40 yr. There were 8 (5%) transient and 2 (1.3%) permanent neurological complications. Among those with neurological complications, 3 had NPM changes during the operation (positive predictive value [PPV] = 50%). This improved to 67% for permanent NPM change. Three patients had NPM changes but did not suffer clinical deficits postoperatively (negative predictive value = 90%). The predictive value of the test was improved for discharge but not 30-d mRS, and the test performance improved dramatically with increased pretest probabilities (likelihood ratio [LR](+) = 14.5, LR(-) = 0.715). CONCLUSION: We present a large series of AVM embolization operations performed with NPM. The PPV of NPM changes was moderate but improved dramatically with increased pretest probabilities. The rate of permanent neurological complications was among the lowest reported in the literature, suggesting NPM may lead to improved intraoperative decision making.

Painless motor radiculopathy of the cervical spine: clinical and radiological characteristics and long-term outcomes after operative decompression.

OBJECTIVE Various neurological diseases are known to cause progressive painless paresis of the upper limbs. In this study the authors describe the previously unspecified syndrome of compression-induced painless cervical radiculopathy with predominant motor deficit and muscular atrophy, and highlight the clinical and radiological characteristics and outcomes after surgery for this rare syndrome, along with its neurological differential diagnoses. METHODS Medical records of 788 patients undergoing surgical decompression due to degenerative cervical spine diseases between 2005 and 2014 were assessed. Among those patients, 31 (3.9%, male to female ratio 4.8 to 1, mean age 60 years) presented with painless compressive cervical motor radiculopathy due to neuroforaminal stenosis without signs of myelopathy; long-term evaluation was available in 23 patients with 49 symptomatic foraminal stenoses. Clinical, imaging, and operative findings as well as the long-term course of paresis and quality of life were analyzed. RESULTS Presenting symptoms (mean duration 13.3 months) included a defining progressive flaccid radicular paresis (median grade 3/5) without any history of radiating pain (100%) and a concomitant muscular atrophy (78%); 83% of the patients were smokers and 17% patients had diabetes. Imaging revealed a predominantly anterior nerve root compression at the neuroforaminal entrance in 98% of stenoses. Thirty stenoses (11 patients) were initially decompressed via an anterior surgical approach and 19 stenoses (12 patients) via a posterior surgical approach. Overall reoperation rate due to new or recurrent stenoses was 22%, with time to reoperation shorter in smokers (p = 0.033). Independently of the surgical procedure chosen, long-term follow-up (mean 3.9 years) revealed a stable or improved paresis in 87% of the patients (median grade 4/5) and an excellent general performance and quality of life. CONCLUSIONS Painless cervical motor radiculopathy predominantly occurs due to focal compression of the anterior nerve root at the neuroforaminal entrance. Surgical decompression is effective in stabilizing or improving motor function with a resulting favorable long-term outcome.

Cortical Hand Knob Stroke: Report of 25 Cases.

BACKGROUND: Although uncommon, cortical hand knob territory stroke is a well-defined stroke entity that mimics peripheral nerve damage. Atherosclerosis and hypertension are the most prevalent risk factors for the disease. Embolic origin, either artery-to-artery or cardioembolic, has been suggested as the most probable underlying mechanism. MATERIALS AND METHODS: Twenty-five patients with isolated hand palsy due to central origin were admitted to our department between 2006 and 2016. Cortical lesions were proven by either computed tomography or magnetic resonance imaging. RESULTS: The average age was 67 ± 12 years. Most of the cases were first-ever strokes (n = 23, 92%). Isolated infarct in the hand knob region was found in 18 of the 25 cases, whereas 7 had multiple acute infarctions. Supra-aortic atherosclerosis was found in 21 patients, 8 of them had 50% or greater ipsilateral stenosis of the internal carotid artery. Hypertension was the second most prevalent risk factor (n = 20, 80%). Quick improvement of symptoms was seen in almost every case (mean follow-up 17.5 months), 9 patients showed complete recovery, whereas 2 remained disabled and 1 died due to a malignant disease. Three patients suffered a recurrent stroke on follow-up. CONCLUSIONS: We conclude that distal arm paresis is a rare presentation of acute stroke with usually benign course.

Amygdalohippocampotomy for mesial temporal lobe sclerosis: Epilepsy outcome 5 years after surgery.

BACKGROUND: The goal of the present study is the evaluation of the long-term clinical outcome of epilepsy in patients with mesial temporal lobe sclerosis (MTLS) submitted to amygdalohippocampotomy (AHCo). AHCo consists of the lateral ablation of the amygdala and the peri-hippocampal disconnection instead of amygdalohippocampectomy (AHC), which involves the removal of both structures. We previously reported the short-term results of AHCo, so we here present the long-term results (> 5 years of follow-up) of the patients operated on with AHCo. METHOD: Since 2007, 35 patients (22 females) aged 20-61 years (mean: 42 years) were operated on with the AHCo technique, 17 patients on the left side and 18 on the right. Of these patients, 21 (14 females) have been followed up > 5 years (5 to 7.5 years, mean 6.5 years). We compare the present results with those observed shortly after surgery and with the patients operated on with AHC. FINDINGS: In all 21 cases, the diagnosis was mesial temporal lobe sclerosis (histology confirmed in 20), 11 on the left side and 10 on the right. Epilepsy results after 5 years were good/very good in 18 patients (85.7%), with Engel class IA-B in 15 (71.4%) and II in 3 (14.3%), and bad in 3 patients, with Engel Class III in 2 (9.5%) and class IV in 1 (4.8%). Concerning morbidity, one patient had hemiparesis (hypertensive capsular hemorrhage 24 h after surgery), two verbal memory worsening, two quadrantanopia and three late depression that was reversed with medication. Comparatively, the AHC long-term results were 87% Engel class I, 8% Engel class II and 5% Engel class III-IV. The morbidity was equally small. CONCLUSIONS: The good/very good results of AHCo 5 years after surgery are 86%, which is not distinct from the AHC results. So AHCo seems to be effective and potentially safer than AHC in long-term follow-up.

The advantage of early plication in children diagnosed with diaphragm paresis.

BACKGROUND: In this single-center study, we sought to determine the frequency of phrenic nerve injury leading to diaphragm paresis (DP) in children following open cardiac surgery over the last 10 years, and to identify possible variables that predict the need for plication and associated clinical outcomes. METHODS: Patients diagnosed with DP were identified from departmental databases and a review of clinical diaphragm ultrasound images. A cohort was analyzed for predictors of diaphragm plication and associations with clinical outcomes. Cumulative proportion graphs modeled the association between plication and length of stay. RESULTS: DP was diagnosed in 161 of 6448 patients (2.5%) seen between January 2002 and December 2012. All diagnoses but 1 were confirmed by ultrasound. Plication of the diaphragm was performed in 30 patients (19%); compared with patients who did not undergo plication, these patients were younger (median age, 10 days vs 138 days; P < .001), more likely to have undergone deep hypothermic circulatory arrest (47% vs 18%; P = .005), had a longer duration of positive pressure ventilation (median, 15 days vs 7 days; P < .001), and had longer lengths of stay in both the intensive care unit (median, 23 days vs 8 days; P < .0001) and the hospital (median, 37 days vs 15 days; P < .0001). Early plication was associated with reduction in all intervals of care. CONCLUSIONS: Early plication should be considered for patients with diaphragm paresis requiring prolonged respiratory support after cardiac bypass surgery. Longer follow-up evaluation is required to better define the long-term implications of plication.

Superior Sagittal Sinus Obstruction by Giant Meningiomas: Is Total Removal Feasible?

OBJECTIVE: To present our experience with microsurgical technique for patients with giant meningiomas (maximum diameter ≥7 cm) that obstruct the superior sagittal sinus (SSS). METHODS: All patients who were preoperatively diagnosed (between 2010 and 2014) with giant meningiomas involving the SSS in Ward 10 at the Neurosurgery Department of Beijing Tiantan Hospital were enrolled in this study. Patient charts, imaging findings, and outcomes were examined. RESULTS: The study included 6 male and 4 female patients with a mean age of 46.8 ± 10.7 years. The tumor sizes varied from 7 to 12 cm (mean, 8.8 ± 2.0 cm). All patients underwent customized craniotomies, and aggressive surgery for resection of the invaded SSS was performed. Simpson grade I removals were achieved in all cases. No cases of perioperative mortality occurred. Three patients required cranioplasty as a result of a decompressive craniectomy that was performed during the primary surgery. Histologic examinations showed 1 malignant and 9 benign meningiomas. During the follow-up period (mean, 29.0 ± 9.7 months), recurrence/progression occurred in 1 patient, and 1 patient was lost to follow-up. The recent Karnofsky Performance Score was 80 ± 32.3 and was improved in 5 patients and stabilized in 3 patients. In addition, 7 patients lived independently. CONCLUSIONS: The rigorous preservation of cortical veins, draining veins, and eloquent areas should be implemented during the resection of large tumors that obstruct the SSS. Suitable individualized approaches associated with full exposure and low cerebral perfusion pressure levels after surgery are critical for favorable results, and the reconstruction of the SSS may not be necessary.

Role of Intraoperative Neurophysiologic Monitoring in the Resection of Thalamic Astrocytomas.

BACKGROUND: The thalamus is a deep-seated and crucial structure for the sensorimotor system. It has been long considered a surgically inaccessible area because of the morbidity associated with surgical resections. Astrocytomas of the thalamus are usually treated with bioptic procedures followed by adjuvant treatments. Intraoperative neurophysiologic monitoring (IONM) allows safe and satisfactory resections of lobar gliomas, but few data are available for thalamic lesions. The aim of this study was to review the outcome of a small series of patients with thalamic astrocytomas that were treated with surgical resection with the aid of IONM. METHODS: Surgical resection with IONM was performed in 5 patients with thalamic astrocytomas (1 grade I, 1 grade II, 2 grade III, 1 grade IV). Two astrocytomas were in the dominant hemisphere. Preoperative and postoperative neuropsychological assessments were performed in 3 patients. IONM was tailored to the individual patient and consisted of transcranial motor evoked potential monitoring, cortical motor evoked potential monitoring, somatosensory evoked potential monitoring, direct electrical stimulation, electroencephalography, and electrocorticography. RESULTS: None of the patients experienced permanent motor deficits; 2 patients had a transient hemiparesis requiring rehabilitation; 1 patient had a transient aphasia, and 1 patient had permanent aphasia. None of the patients had intraoperative seizures, but 1 patient experienced postoperative transient status epilepticus. The extent of resection on postoperative volumetric magnetic resonance imaging was >70% in all cases. CONCLUSIONS: Surgical resection of thalamic astrocytomas appeared to be effective and relatively safe when guided by IONM. Larger series of patients are required to confirm these preliminary data.

12-year retrospective study of Sturge-Weber syndrome and literature review.

OBJECTIVE: To review the clinical manifestations and neuroimaging features of patients with Sturge-Weber syndrome (SWS) treated at Srinagarind Hospital over a 12-year period. MATERIAL AND METHOD: A retrospective study of sixteen patients with SWS (9 males and 7 females) was conducted. The medical records, photographs, and neuroimaging studies were reviewed RESULTS: All patients had port-wine stain (PWS) involving the eyelid. Bilateral cutaneous lesions were revealed in four patients (25%). Glaucoma was the main ocular disease being diagnosed in 11 eyes of nine patients (56.25%); four eyes were finally blind. The cyclodestructive procedure and/or surgical treatment was required in four eyes. Other ocular abnormalities were refractive error dilated episcleral vessels, corneal abnormalities, tortuous retinal vessels, choroidal hemangioma, amblyopia, and strabismus. Twelve patients (75%) had neurological impairment including seizure, hemiparesis, headache, and delayed development. However the most common neurological manifestation was epilepsy (75%), which could be controlled with antiepileptic drugs. Neurological imaging was performed in the majority of cases (14 patients). Intracranial abnormalities were demonstrated in 11 patients (78.57%). These included cerebral atrophy (81.82%), cerebral calcification (54.55%), leptomeningeal angioma (27.27%), and enlarged choroidal plexus (27.27%). The ocular complication and intracranial abnormalities were usually ipsilateral to the PWS. One patient with unilateral PWS, however had bilateral intracranial lesion. CONCLUSION: Port-wine stains, glaucoma, and seizure were the most common clinical features of Sturge-Weber syndrome detected in the present study. Complete ophthalmic and neurological evaluation should be performed at the time ofdiagnosis. Multidisciplinary team management as well as lifelong follow-up is needed.

Predictors of venous thromboembolism recurrence and bleeding among active cancer patients: a population-based cohort study.

Active cancer is the major predictor of venous thromboembolism (VTE) recurrence, but further stratification of recurrence risk is uncertain. In a population-based cohort study of all Olmsted County, Minnesota, residents with active cancer-related incident VTE during the 35-year period from 1966 to 2000 who survived 1 day or longer, we estimated VTE recurrence, bleeding on anticoagulant therapy, and survival and tested cancer and noncancer characteristics and secondary prophylaxis as predictors of VTE recurrence and bleeding, using Cox proportional hazards modeling. Of 477 patients, 139 developed recurrent VTE over the course of 1533 person-years of follow-up. The adjusted 10-year cumulative VTE recurrence rate was 28.6%. The adjusted 90-day cumulative incidence of major bleeding on anticoagulation was 1.9%. Survival was significantly worse for patients with cancer who had recurrent VTE (particularly pulmonary embolism) and with bleeding on anticoagulation. In a multivariable model, brain, lung, and ovarian cancer; myeloproliferative or myelodysplastic disorders; stage IV pancreatic cancer; other stage IV cancer; cancer stage progression; and leg paresis were associated with an increased hazard, and warfarin therapy was associated with a reduced hazard, of recurrent VTE. Recurrence rates were significantly higher for cancer patients with 1 or more vs no predictors of recurrence, suggesting these predictors may be useful for stratifying recurrence risk.

Risk factor analysis of the development of new neurological deficits following supplementary motor area resection.

OBJECT: Supplementary motor area (SMA) resection often induces postoperative contralateral hemiparesis or speech disturbance. This study was performed to assess the neurological impairments that often follow SMA resection and to assess the risk factors associated with these postoperative deficits. METHODS: The records for patients who had undergone SMA resection for pharmacologically intractable epilepsy between 1994 and 2010 were gleaned from an epilepsy surgery database and retrospectively reviewed in this study. RESULTS: Forty-three patients with pharmacologically intractable epilepsy underwent SMA resection with intraoperative cortical stimulation and mapping while under awake anesthesia. The mean patient age was 31.7 years (range 15-63 years), and the mean duration and frequency of seizures were 10.4 years (range 0.1-30 years) and 14.6 per month (range 0.1-150 per month), respectively. Pathological examination of the brain revealed cortical dysplasia in 18 patients (41.9%), tumors in 16 patients (37.2%), and other lesions in 9 patients (20.9%). The mean duration of the follow-up period was 84.0 months (range 24-169 months). After SMA resection, 23 patients (53.5%) experienced neurological deficits. Three patients (7.0%) experienced permanent deficits, and 20 (46.5%) experienced symptoms that were transient. All permanent deficits involved contralateral weakness, whereas the transient symptoms patients experienced were varied, including contralateral weaknesses in 15, apraxia in 1, sensory disturbances in 1, and dysphasia in 6. Thirteen patients recovered completely within 1 month. Univariate analysis revealed that resection of the SMA proper, a shorter lifetime seizure history (<10 years), and resection of the cingulate gyrus in addition to the SMA were associated with the development of neurological deficits (p=0.078, 0.069, and 0.023, respectively). Cingulate gyrus resection was the only risk factor identified on multivariate analysis (p=0.027, OR 6.530, 95% CI 1.234-34.562). CONCLUSIONS: Resection of the cingulate gyrus in addition to the SMA was significantly associated with the development of postoperative neurological impairment.

Reoperation after failed resective epilepsy surgery.

PURPOSE: Resection of the seizure focus leads to sustained seizure-freedom in intractable focal epilepsy in up to 80% of selected populations. However, surgery fails to help in a considerable proportion of patients. Reevaluation and reoperation may be considered in a selected group of patients with an unfavorable postsurgical outcome. Here, we reviewed 15 case series on reoperation after failed resective epilepsy surgery in adults in order to identify factors associated with a good chance of benefitting from a second operation. METHODS: Literature review of case series describing the outcome of epilepsy surgical re-operations. RESULTS: Overall, 3.8-14% of all patients who had resective epilepsy surgery underwent a second operation. A total of 402 reoperated patients were included. Reoperation was performed in average between 2 and 5.5 years after the first surgery. 36.6% of all patients were seizure-free with a minimal follow-up of 6 months to 4 years after the second operation. Postsurgical complications were observed in 13.5% and mainly consisted of visual field defects and, less frequently, of hemiparesis. The causes of failed first epilepsy surgery were heterogeneous and included incorrect localization or incomplete resection of the seizure focus, presence of additional seizure foci or progression of the underlying disease. Some features appear to indicate successful reoperation, such as concordance of postsurgical imaging and electroclinical findings as well as absence of brain trauma and cerebral infection prior to epilepsy onset. CONCLUSION: Reoperation after thorough assessment of all available clinical, imaging and EEG findings can be an efficacious and reasonably safe treatment option which can achieve sustained seizure control after failed resective epilepsy surgery.

Risk factors of neurological complications in cardiac surgery.

BACKGROUND: Postoperative complications are integral to cardiac surgery. The most serious ones are stroke, which develops in about 7.5% of the patients, and postoperative encephalopathy, which affects 10-30% of the patients. According to bibliographical data, the number of complications is increasing. AIM: To analyse the risk factors and the types of neurological complications in patients undergoing heart surgery. METHODS: We assessed retrospectively 323 consecutive patients undergoing surgery at the Department of Cardiac Surgery, University Teaching Hospital, Medical University of Bialystok, Poland, between July 2007 and June 2008. Group 1 comprised patients without neurological complications (n = 287; 89%) and Group 2 consisted of patients with neurological complications (n = 36; 11%). Our analysis included the following: preoperative status (age, sex, co-morbidities), intraoperative course (surgery type, duration of cardiopulmonary bypass [CPB], duration of aortic cross-clamping, types of medications administered, necessity of reinfusion from the cardiotomy reservoir and the necessity of tranexamic acid infusion) and the postoperative course (time to regaining consciousness, duration of mechanical ventilation, development of complications, types of complications). The results were then analysed statistically: arithmetic means and standard deviations were calculated for quantitative variables and the quantitative and percentage distributions were calculated for qualitative variables. The between- group comparisons of the quantitative variables were carried out using the t-Student test, while the qualitative variables were compared using the χ(2) test. The variables that proved significant in the univariate comparisons were included in the multivariate model. Regression analysis was the final step of the analysis of the risk factors for neurological complications. Based on the analysis of the ROC curve we calculated the cutoff values for the continuous variables. We calculated odds ratios with their 95% confidence intervals. P values of less than 0.05 were considered statistically significant. RESULTS: Among the 36 patients in Group 2, postoperative encephalopathy developed in 22 patients, transient ischaemic attacks in 7 patients, ischaemic stroke in 6 patients (associated with right hemisphere damage in 3 patients and with left hemisphere damage in 3 patients) and haemorrhagic stroke in 1 patient (right hemisphere). Early mortality was 5% with 2 (0.69%) patients dying in Group 1 and 14 (38.9%) in Group 2. Univariate analysis revealed that the preoperative risk factors of neurological complications were: age >68 years (with a cutoff value of 58.5 years), a history of stroke with paresis, atrial fibrillation (AF) and a euroSCORE of >6 (with a cutoff value of 4.5). The peri- and postoperative risk factors included: surgery type (complex coronary and valvular surgeries aortic valve surgeries), duration of CPB of >142 min, duration of aortic crossclamping of >88 min, mean perfusion pressure during CPB of <70 mm Hg, haemodilution manifested by a haematocrit (HCT) of <28%, perfusate supply, time to regaining consciousness of >14.5 h and duration of artificial ventilation of >30.5 h. Multivariate analysis revealed the following factors to increase the risk of neurological complications: long duration of ventilation, a history of stroke with paresis, AF, low HCT values and long duration of aortic cross-clamping. The Nagelkerke R2 coefficient of determination was 0.636, the sensitivity was 74.36%, the specificity was 97.545% and the accuracy was 94.74%. CONCLUSIONS: In patients undergoing heart surgery, the independent risk factors of neurological complications in the first 30 days include: long duration of ventilation, a history of stroke with paresis, AF, haemodilution manifested by an HCT of <28% and long duration of aortic cross-clamping. Neurological complications are associated with high postoperative mortality.

Perioperative complications of anterior cervical decompression with fusion in patients with ossification of the posterior longitudinal ligament: a retrospective, multi-institutional study.

BACKGROUND: Anterior decompression with fusion (ADF) for patients with cervical ossification of the posterior longitudinal ligament (OPLL) is reportedly associated with a higher incidence of complications than is laminoplasty. However, the frequency of perioperative complications associated with ADF for cervical OPLL has not been fully established. The purpose of this study was to investigate the incidence of perioperative complications, especially neurological complications, following ADF performed to relieve compressive cervical myelopathy due to cervical OPLL. METHODS: Study participants comprised 150 patients who had undergone ADF for cervical OPLL at 27 institutions between 2005 and 2008. Perioperative--especially neurological--complications occurring within 2 weeks after ADF were analyzed. Preoperative imaging findings, including Cobb angle, between C2 and C7 and occupying ratio of OPLL were investigated. Multivariate analysis with logistic regression was performed to identify independent risk factors for neurological complications. RESULT: Three patients (2.0 %) showed deterioration of lower-extremity function after ADF. One of the three patients had not regained their preoperative level of function 6 months after surgery. Upper-extremity paresis occurred in 20 patients (13.3 %), five of whom had not returned to preoperative levels 6 months after surgery. Patients with upper-extremity paresis showed significantly higher occupying ratios of OPLL, greater blood loss, longer operation times, fusion of more segments, and higher rates of cerebrospinal fluid leakage than those without paresis. Independent risk factors for upper-extremity paresis were a high occupying ratio of OPLL and large blood loss during surgery. CONCLUSIONS: The incidences of deterioration in upper- and lower-extremity functions were 13.3 % and 2.0 %, respectively. Patients with a high occupying ratio of OPLL are at higher risk of developing neurological deterioration.

Occurrence and clinicotopographical correlates of brainstem infarction in patients with diabetes mellitus.

BACKGROUND: The goal of the study was to clarify the association between diabetes mellitus (DM) and brainstem infarctions (BSIs) and to investigate the clinicotopographic characteristics of BSIs in patients with diabetes. METHODS: Data were retrospectively reviewed for 1026 consecutive patients admitted to our hospital because of acute cerebral infarctions from January 2004 to August 2010. Acute symptomatic BSIs were explored on radiologic images and classified into multiple infarctions with BSIs, multifocal BSIs, and monofocal BSIs. Isolated BSIs were further classified based on the vertical distribution into midbrain, pontine, and medullary infarctions, and on the horizontal distribution into anterior-dominant, posterior-dominant, and anterior/posterior BSIs. Neurologic symptoms of BSIs and clinical background were compared between DM and non-DM patients. RESULTS: The prevalence of BSIs was 2.6-fold higher (P < .0001) in DM patients. Logistic regression analysis including age, sex, smoking, previous stroke, atrial fibrillation, other cardiac diseases, hypertension, hyperlipidemia, and DM showed that DM was independently associated with BSIs (odds ratio [OR] 2.814; 95% confidence interval [CI] 1.936-4.090; P < .0001). Compared with non-DM patients, DM patients showed more frequent monofocal BSIs (P < .0001) and multifocal BSIs (P = .0296). Monofocal BSIs (n = 114) more frequently involved the pons (P < .0001) and medulla (P = .0212). Anterior-dominant BSIs (P < .0001) were more common in DM patients than in non-DM patients. Symptoms of BSIs included more frequent motor paresis (P = .0180) and less frequent diplopia (P = .0298) in DM patients than in non-DM patients. CONCLUSIONS: DM is important in the development of BSIs, and the associated clinical characteristics include more frequent motor paresis and less frequent diplopia.

Sturge-Weber syndrome in patients with facial port-wine stain.

Facial port-wine stain (PWS) may be associated with cerebrovascular abnormalities such as Sturge-Weber syndrome (SWS). In a large series, we aimed to assess which topography of facial PWS can predict SWS. This was a cross-sectional study of consecutive patients with facial PWS seen in pediatric dermatologic or angiodysplasia consultations from 1993 to 2005 at the University Hospital Center of Tours. A standardized form was used to collect data on clinical and imaging findings. Patients with and without SWS were compared in terms of topography of the cutaneous angioma and related ophthalmologic and neurologic features. Two hundred fifty-nine patients were included, 15 with a diagnosis of SWS. All patients with SWS showed involvement of the V1 trigeminal cutaneous area. SWS was significantly associated with bilateral topography of the PWS, its extension to another territory, and involvement of the upper eyelid. Knowledge of the topography of facial PWS with risk of associated neurological or ocular anomalies allows for early diagnosis of SWS and avoids unnecessary and costly radiography for patients with uncomplicated facial PWS.

Recovery of muscle strength after microdiscectomy for lumbar disc herniation: a prospective cohort study with 1-year follow-up.

BACKGROUND: Surgery has not been proven to be a better treatment option than non-operative management for limb paresis due to lumbar disc herniation. For the patients it will still be a concern, whether they will regain full strength after the operation or not. METHODS: A prospective cohort study of 91 patients with preoperative paresis due to disc herniation with 1-year follow up was carried out. The primary outcome was muscle strength in affected limb, and the secondary outcome was self-reported symptoms on back and leg pain, disability, health related quality of life, general health and working capability. RESULTS: Seventy-five percent of patients had no paresis 1 year after the operation. The severity of the paresis was the only predictor for persistent paresis. Preoperative duration of the paresis did not influence the rate of full recovery. Non-recovery was associated with inferior outcomes and higher risk for reduced working capability. CONCLUSIONS: The majority of patients with paresis were fully recovered 1 year after microdiscectomy for lumbar disc herniation. If the paresis was severe at baseline, there was a four times higher risk for non-recovery. Patients who did not recover had significantly worse outcomes.

Stroke awareness in Denmark.

BACKGROUND: This is the first study to examine the awareness of major stroke symptoms and stroke risk factors among the general population in Denmark. Early recognition of stroke warning signs and means of reducing stroke occurrence could improve the treatment and prevention of stroke. METHODS: A total of 3,520 subjects were invited to participate in the study, using a web-based, closed questionnaire. The recruitment was stratified by region, age and gender to represent the composition of the general Danish population aged 40+ years. Enrollment was competitive with a predefined target of 800 responses. The subjects were asked to rank the 4 most important acute stroke symptoms, and the 3 most important risk factors for stroke. Multivariable ordinal logistic regression was used for assessing factors associated with awareness of stroke symptoms and major stroke risk factors. RESULTS: From December 12 to December 17, 2008, a total of 811 subjects (mean age: 58 years; SD: 11 years) were included, of which 405 (50%) were women. The 4 most frequently identified stroke symptoms were sudden onset of: speech disturbances (n = 636; 78.4%), facial palsy (n = 450; 55.5%), hemiparesis (n = 435; 53.6%) and visual disturbances (n = 429; 52.9%). The 3 most frequently identified stroke risk factors were: hypertension (n = 586; 72.3%), history of cerebrovascular disease (n = 401; 49.5%) and high concentration of cholesterol (n = 269; 33.2%). Compared with men, women had better knowledge of major stroke symptoms (OR = 1.33; 95% CI: 1.12-1.50) and stroke risk factors (OR = 1.33; 95% CI: 1.10-1.51) in multivariable analyses. CONCLUSIONS: The awareness of major stroke symptoms is insufficient. Whereas hypertension was the most often mentioned stroke risk factor, few subjects recognized tobacco smoking and diabetes mellitus as major risk factors for stroke.