Locked-in syndrome following elective cervical foraminotomy: a case report.

INTRODUCTION: There are no previously reported cases of locked-in syndrome occurring following cervical spinal surgery. We describe a case of locked-in syndrome following an elective cervical foraminotomy and discuss potential etiologies and contributing factors to our patient's presentation. CASE PRESENTATION: A 54-year-old male with a history of head and neck cancer and prior anterior cervical discectomy and fusion presented with neck pain following a motor vehicle accident. The patient underwent C4-C7 left-sided cervical posterior foraminotomy with no intraoperative complications. On postoperative day 1, the patient suddenly developed rapidly progressing weakness of the extremities and soon became non-verbal. CT angiography and near-infrared spectroscopy confirmed a basilar artery occlusion and left vertebral artery dissection. On MRI, infarcts involving the bilateral pons, left cerebral hemisphere, and left cerebellar infarct were identified. CONCLUSION: The etiology of locked-in syndrome in our patient remains unclear, but it is likely multifactorial. It is possible that the patient was predisposed to vascular injury from prior radiation therapy to the head and neck. In addition, intraoperative vascular insult may have occurred from vibrational shear stress, in turn leading to a vertebral artery dissection, basilar artery occlusion, and pontine infarct, ultimately resulting in our patient's locked-in state.

Anesthetic Considerations for Patients with Locked-In Syndrome Undergoing Endoscopic Procedures.

BACKGROUND Delivering safe anesthetic care to a patient unable to communicate easily and effectively with the anesthesia team presents many unique challenges. Communication may be limited by language, which can be resolved with translation services, or neurological conditions, such as stroke or traumatic brain injury, which are not easily remedied. In such patients, the inability to communicate effectively can lead to anxiety and negatively impact the patient-anesthesiologist relationship, especially when higher cognitive functions are preserved. CASE REPORT We present a case of a patient with locked-in syndrome (LIS), who presented to our endoscopy unit for a routine colonoscopy. The patient could only communicate with eye movements and blinking, thus limiting our ability to assess their pain or other needs in the perioperative period; however, she was otherwise cognitively intact. By utilizing the patient's home healthcare team and quickly adapting their unique communication methods during the perioperative period, we were able to provide an appropriate, safe anesthetic for this patient with LIS. CONCLUSIONS Many patients requiring an anesthetic are unable to effectively communicate due to language issues, hearing loss/mutism, neurological injury/stroke (aphasia), or developmental disabilities. The unique communication needs of this patient with LIS went beyond utilizing a translator and required the healthcare team to quickly learn a new communication method. We also discuss forms of intraoperative monitoring that can be used to differentiate consciousness from the anesthetized state in LIS patients, as well as making recommendations for future care of such patients.

Locked-in syndrome responding to endovascular treatment.

BACKGROUND: Locked-in syndrome (LiS) is a rare and devastating condition in patients with acute basilar artery occlusion. However, the benefits of endovascular treatment (EVT) for LiS remain unclear. OBJECTIVE: To assess the outcomes associated with EVT and identify the factors associated with outcomes of LiS. METHODS: We used the data of the Endovascular Treatment for Acute Basilar Artery Occlusion Study Registry (BASILAR) from 47 tertiary stroke centers in China. The included patients had LiS and received EVT or standard medical treatment (SMT) alone. The primary outcome was improvement in the modified Rankin Scale (mRS) score at 90 days. RESULTS: Among the 120 patients with LiS, 92 (76.7%) received EVT and 28 (23.3%) received SMT. Compared with SMT, EVT was associated with improved mRS score (common OR (cOR)=2.68 (95% CI 1.16 to 6.20); p=0.02) and decreased mortality (aOR=0.35 (95% CI 0.13 to 0.90); p=0.03). Moreover, the benefit of EVT for LiS was sustained for at least 1 year (p=0.008). Higher baseline posterior circulation Alberta Stroke Prognosis Early CT Score (pc-ASPECTS, aOR=2.04 (95% CI 1.34 to 3.10); p<0.001) and absence of pneumonia (aOR=0.26 (95% CI 0.08 to 0.90); p=0.03) were significantly associated with favorable functional outcome at 90 days in patients who received EVT, while lower pc-ASPECTS (aOR=0.52 (95% CI 0.36 to 0.76); p<0.001) was associated with increased 90-day mortality. CONCLUSIONS: This study found that EVT was associated with favorable functional outcomes and decreased mortality among patients with LiS. Baseline pc-ASPECTS and pneumonia were independent predictors of outcomes.

Toma de decisiones en ética clínica y su aplicación a un caso de síndromede enclaustramiento / Decision making in clinical ethics and its application to a locked-in case

La ética clínica, como parte de la bioética, tiene como función ayudar al personal sanitario, al paciente o a la familia en la toma de de-cisiones cuando estas abordan cuestiones éticas de difícil solución. En algunos problemas, esta toma de decisiones se enfrenta no solo a posturas clínicas diversas, sino que también a apremios por parte de familiares -o del mismo equipo médico- que claman por una solución ante casos que entran en el área gris del debate ético. Nuestra respuesta frente a estos problemas ingentes es la aplicación de un método de análisis clínico, el cual, mediante una metodología propia y replicable, pueda orientar la discusión sobre principios comunes y, a la vez, poder evaluar las decisiones clínicas emanadas.Más allá de las respuestas clínicas que se puedan dar frente a casos diversos, no debemos olvidar los fundamentos que la antropología cristiana nos presenta a la hora de ver al ser humano como totalidad unificada. Este criterio debe ser la base que guíe una reflexión que no solo busque criterios de calidad, sino que además valore la inviolabilidad de la vida y con ella la dignidad de cada persona, en especial, en aquellas condiciones de fragilidad como el síndrome de enclaustramiento.

Clinical ethics (as part of bioethics) has the function of helping health personnel, the patient, or the family in decision-making when they address ethical issues that are difficult to solve. In some problems, this decision-making is not only confronted with diverse clinical positions, but also by pressure from family members or the same medical team that clamour for a solution to cases that fall into the grey area of ethical debate. Our response to these enormous problems is the application of a method of clinical analysis which, through its own replicable methodology, can guide the discussion of common principles and, at the same time, be able to evaluate the clinical decisions that have been made.Beyond the clinical responses that can be given to diverse cases, we must not forget the foundations that Christian anthropology presents us when it comes to seeing man as a unified whole, this criterion must be the basis that guides a reflection that not only look for quality criteria but value the inviolability of life and with it the dignity of each person especially in those conditions of fragility, such as locked-in.

Abordaje fonoaudiológico de la deglución en el Síndrome de Enclaustramiento / Intervention approach for speech -language pathologists to swallowing in Locked-in Syndrome

n el Síndrome de Enclaustramiento las manifestaciones clínicas son preponderantemente de orden motor, situación que requiere la intervención del Fonoaudiólogo, dado el compromiso comunicativo y de la biomecánica deglutoria. La disfagia en este síndrome está dada por la desconexión sensorio-motriz de las estructuras anatómicas de la deglución, alterando la secuencia neuromotora y sensitiva del proceso deglutorio debido a la desconexión pontina. El texto presenta el caso de una paciente femenina de 27 años quien es diagnosticada con Síndrome de Eclaustramiento posterior a accidente cerebrovascular de Arteria Basilar Derecha, acto que compromete sus habilidades motoras de forma generalizada. A partir de su diagnóstico y dadas las características multicéntricas de la deglución, se objetiva comenzar intervención fonoaudiológica oportuna, estableciendo como eje fundamental la secuencialidad de los procesos neurofisiológicos de la deglución; adoptando como estrategia el manejo de consistencias, fortaleciendo sensorial y motrizmente la deglución. Al intervenir las necesidades sensoriomotoras orales en pro de la alimentación, y usando como estrategias terapéuticas la modificación de consistencias, manejo de volumen, postura, aditamento para suministro de alimento y tiempos de ingesta, se minimizan los riesgos en el proceso de alimentación y se puedo llegar a mantener un estado nutricional y de hidratación óptimo para la recuperación física general, permitiendo el aumento de la ingesta en una proporción inicial de 30% vía oral - 70% vía enteral a un 100% incluyendo a la dieta el nivel 4-puré, según la IDDSI y desarrollando paralelamente procesos de interacción familiar, impactando su calidad de vida.

he clinical manifestations of Locked-In Syndrome are predominantly motor in order, a situation that requires the intervention of the speech therapist, given the communicative disorder and biomechanics of swallowing. The dysphagia in this syndrome is produced by the sensibly-motor disconnection of the anatomical structures of swallowing, altering the neuromotor and sensitive sequence of the swallowing process because of the pontine disconnection. The text presents the case of a 27-year-old female who is diagnosed with Locked-In Syndrome after suffering a cerebrovascular accident in the Basilar Right Artery, which compromises her motor skills. From her diagnosis and given the characteristics of swallowing, it is necessary to begin speech therapy intervention, focusing the sequences of the neurophysiological processes of swallowing; using as a strategy the management of consistency, strengthening sensory and motor swallowing. After intervening the oral sensory motor, improving nutrition, and using as therapeutic strategies the modification of consistency, volume, posture, food supply and intake times. The risks in the feeding process are minimized, the nutritional status and optimal hydration can be maintained for the overall physical recovery, allowing the increase of intake with an initial proportion of 30% orally - 70% through enteral to 100%, including the 4-Pureed level, according to the IDDSI and developing parallel processes of family interaction, impacting their quality of life.

[Locked-in Syndrome due to Primary Brainstem Injury:A Case Report].

Most cases of the primary brainstem injuries(PBSI)are fatal, and disturbance of consciousness is often prolonged even if lifesaving is obtained. The mechanisms of PBSI are as follows: diffuse axonal injury from acceleration/deceleration, shear strain at the midbrain, direct injury of neurovascular structures by tentorial margin, and lower brainstem injury by hyperextension of the cervical vertebrae. Though we can use both CT and MRI to diagnose, MRI is more helpful than CT in detecting, localizing, and characterizing PBSI. When the location of PBSI is limited in the ventral side of pons, it may occasionally result in locked in syndrome(LIS). Generally it is difficult to diagnose LIS with severe trauma due to the rarity of this syndrome caused by head injury. Here, we report a case of an elderly man with traumatic brainstem hemorrhage, who transiently presented LIS and finally improved.

Valoraciones morales de profesionales de la salud sobre el estatuto ontológico de la persona al final de la vida / Moral valuation of health professionals about he ontological statute of the pperson at the end of tee life / Valoação moral ddos profissionais da saúde sobre o etatuto ontológiico da pessoa no final da vida

El espacio de reflexión y debate que ofrece la Bioética debe ser aprovechado, fundamentalmente, en temas tan escabrosos como comprometedores con la existencialidad del hombre. Con el avance impetuoso de la ciencia y la tecnología, los límites entre la vida y la muerte se han dilatado, el contexto del espacio y el tiempo en que se desarrolla la muerte humana ha cambiado. Y no es que no se muera o que se muera mucho menos que en tiempos remotos, sino que los dilemas que se configuran alrededor de la muerte son otros. El poder resolutivo de las ciencias biomédicas hace que cada día nos encontremos ante eventos nunca antes pensados por el hombre por los que surgen estados ontológicos generan dudas sobre referentes éticos solidificados por el hombre. ¿Qué entender por persona? ¿Qué es la muerte? ¿Cómo asumirla? Todas son preguntas que marcan el hilo conductor de la reflexión para responder ante los conflictos de la existencialidad humana en los límites ahora movedizos de la vida.

The opportunity of reflection and debate that offers Bioethics must be well-planned, essentially in crude issues as compromising with the existence of the man. With the impetuous advance of science and the technology the limits between the life and the death have dilated, the context space time in which the human death is developed has changed, is not that it does not die or that dies much less that in remote times, but the dilemmas that are formed around the death are others. The decisive power of biomedical sciences causes that every day we are before events never thought before by the man, arise ontological states that put in crisis and doubt ethical episteme solidified by the man.

E necessário explorar o espaço de reflexão e debate que oferece a bioética, sobretudo em áreas tão delicadas, relacionadas com a existência humana. Com o rápido avanço da ciência e da tecnologia, têm-se ampliados os limites entre a vida e a morte, mudou o contexto espaço-tempo em que se desenvolve a morte humana. Não é que ninguém morra nem menos pessoas morram hoje do que outros tempos, mas são diferentes os dilemas em torno da morte. O poder de resolução das ciências biomédicas permite que ocorram eventos diários jamais concebidos pelo homem; surgem estados ontológicos que põem em crise e questionam alguns epistemes éticos petrificados pelo homem.

Fisiopatologia do estresse em animais selvagens em cativeiro e suas implicações no comportamento e bem-estar animal: revisão da literatura / Physiopathology of stress in captive wild animals and its implications on animal behaviour and well-being: a review

Estimativas atuais sugerem que a população animal está diminuindo na natureza, principalmente pela ação humana na destruição de hábitats. Desta forma, a criação de animais selvagens em cativeiro vem ganhando importância na conservação de espécies. No entanto, a manutenção desses animais em um ambiente artificial e não estimulante pode trazer sérios problemas para sua saúde e comportamento, problemas estes normalmente relacionados a condições estressantes do cativeiro. Portanto, uma vez que o cativeiro se torne, algumas vezes, necessário para a conservação da vida selvagem, deve-se ter uma preocupação com o bem-estar animal, utilizando-se para isso técnicas para estimular o interesse do animal pelo ambiente em que se encontra e reduzir o seu padecimento. Este trabalho descreve os eventos relacionados ao estresse,com o objetivo de apresentar as suas possíveis implicações na saúde e no bem-estar animal, enfatizando a importância da observação do comportamento como um indicador do estresse e sugerindo alguns métodos para reduzir o sofrimento animal durante o período decativeiro.

Current estimates suggest that the animal population is decreasing in nature, especially due to human actions in habitat destruction. From this point of view, the captive breeding of wild animals is becoming important to conserve species. However, the maintenance of these animals in an artificial, non-stimulant environment can cause serious health and behaviour problems, usually related to these stressful conditions. Therefore, since captivity is sometimes necessary towild-life conservation, there must be a concern about animals' well-being, by using some techniques that stimulate the interest of the animals to their environment and reduce their suffering. This paper describes the events related to stress, specially their implications in animal health and well-being, emphasizing how important it is to observe the animal behaviour as an indicator of stress and suggesting some methods to reduce animal suffering during confinement periods.