[Predictive value of net water uptake with respect to early neurological improvement after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke].

Objective: To investigate the value of net water uptake (NWU) for predicting early neurological improvement (ENI) after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke. Methods: A case-control study. A total of 132 patients (80 men, 52 women, median age 68 years) with acute anterior circulation large vessel occlusive stroke receiving endovascular treatment were retrospectively analyzed at Jinling Hospital from October 2014 to September 2019. Patients were divided into two groups based on the occurrence of ENI, which was defined as either an improvement of NIHSS score of ≥4 points, or an NIHSS score of 0 or 1 at 24 hours after endovascular treatment. The rank sum test, Chi square test, and other methods were used to compare differences in baseline characteristics between the two groups. Logistic regression analysis was used to investigate independent predictors of postoperative ENI. Receiver operating characteristic curve analysis used to assess the capacity of NWU to predict ENI. Results: Of the 132 patients in the study, ENI occurred in 47 and did not occur in 85. In multivariate logistic regression analysis age [odds ratio (OR)=0.940, 95% confidence interval (CI) 0.903-0.979, P=0.003], time from stroke onset to puncture (OR=0.995, 95%CI 0.991-0.999, P=0.025), time from puncture to recanalization/end of operation (OR=0.985, 95%CI 0.974-0.996, P=0.007), NWU (OR=0.762, 95%CI 0.620-0.937, P=0.010), and mTICI (OR=1.644, 95%CI 1.043-2.590, P=0.032) were predictive factors for ENI. Receiver operating characteristic curve analysis indicated that NWU could effectively predict ENI (area under the curve=0.642, 95%CI 0.543-0.741, P=0.007), and prediction accuracy was improved when it was combined with other clinical parameters. Conclusion: NWU is an independent predictor of ENI in patients with acute anterior circulation large vessel occlusive stroke undergoing endovascular treatment.

[The influence of first-line endovascular treatment on clinical outcome in patients with acute vertebrobasilar artery occlusion].

Objective: To compare the effectiveness of first-line mechanical thrombectomy (MT) with other types of endovascular treatment (EVT) in patients with acute vertebrobasilar artery occlusion (VBAO). Methods: From May 2012 to December 2019, acute VBAO patients diagnosed by angiographic examinations were consecutively enrolled from Nanjing Stroke Registry. Patients were divided into first-line MT group who were treated with stent retriever and direct aspiration, and other types of EVT group who underwent intraarterial thrombolysis, tirofiban infusion, balloon dilation, and stent placement etc. Clinical characteristics at baseline with statistical trends (P<0.1) between different groups were analyzed to calculate propensity scores, which were adjusted in binary Logistic regression for the relationship between first-line treatment and clinical outcome. Results: A total of 107 patients were enrolled in this study including 82 males and 25 females with average age 62 years old (35-82). The overall recanalization rate was 82.2% (88/107). During follow-up, 33.6% (36/107) and 37.1% (39/105) patients achieved good outcome (defined as modified Rankin Scale score 0-3) at 90 days and 1 year, respectively. The MT group received EVT earlier than the other types of EVT group (median year: 2017 vs. 2015, P=0.017), as well as higher proportion of atrial fibrillation history (21.6% vs. 0, P=0.002), higher baseline National Institution of Health Stroke Scale scores (median: 26 vs. 23, P=0.049), lower Glasgow Coma Scale scores (median: 6 vs. 7, P=0.027), and longer estimated occlusion to groin-puncture time (median: 367 min vs. 283 min, P=0.023). There were significant differences in the stroke etiologies between two groups (P=0.002). The MT group had a lower ratio of rescue device treatment (28.4% vs. 54.5%, P=0.009). After propensity scores were adjusted, the recanalization rate of MT group was significantly higher than that in the other group [odds ratio (95% confidence interval [CI]):5.201, 95%CI 1.562-17.317, P=0.007]. No difference was noted regarding other clinical outcomes. Subgroup analysis indicated that recanalization rates in patients without atherosclerosis were different between intervention types [odds ratio (95%CI): 7.859, 95%CI 1.469-42.042, P=0.016], while the recanalization rates was comparable in population with atherosclerosis [odds ratio (95%CI): 3.739, 95%CI 0.613-22.812, P=0.153]. Conclusion: In acute VBAO patients, first-line MT is associated with higher recanalization rate compared with other types of EVT, especially in non-atherosclerosis patients.

Over-expression of DJ-1 attenuates effects of curcumin on colorectal cancer cell proliferation and apoptosis.

Since this article has been suspected of research misconduct and the corresponding authors did not respond to our request to prove originality of data and figures, "Over-expression of DJ-1 attenuates effects of curcumin on colorectal cancer cell proliferation and apoptosis, by H. Shang, T. Wang, F. Shang, M. Li, Y. Luo, K.-M. Huang, published in Eur Rev Med Pharmacol Sci 2019; 23 (7): 3080-3087-DOI: 10.26355/eurrev_201904_17591-PMID: 31002157" has been withdrawn. The Publisher apologizes for any inconvenience this may cause. https://www.europeanreview.org/article/17591.

Overexpression of XIST facilitates cell proliferation, invasion and suppresses cell apoptosis by reducing radio-sensitivity of glioma cells via miR-329-3p/CREB1 axis.

OBJECTIVE: Glioma is a malignant brain cancer capable of spreading to the microenvironment. Long non-coding RNA (lncRNA) X inactive specific transcript (XIST) was recognized as a significant regulator in many cancers. However, the molecular mechanism of XIST in glioma cell radio-sensitivity requires further exploration. PATIENTS AND METHODS: The expression of XIST, microRNA (miR)-329-3p and cyclic AMP response element-binding protein 1 (CREB1) was evaluated by quantitative Real-time polymerase chain reaction (qRT-PCR). Cell viability and apoptosis were examined by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT) and flow cytometry, respectively. Transwell assay was performed to detect cell invasion. Protein expression of gamma-H2AX (γ-H2AX) and CREB1 was determined by Western blot. The correlation between miR-329-3p and XIST or CREB1 was determined by dual-luciferase reporter assay. Animal models were established by subcutaneously injecting U251 cells transfected with sh-XIST and sh-NC. RESULTS: XIST and CREB1 were overexpressed whereas miR-329-3p was low-expressed in glioma tumors and cells compared with the normal counterparts. XIST knockdown inhibited cell proliferation, invasion and induced cell apoptosis by enhancing cell sensitivity to X-ray radiation in glioma. Then, we discovered that miR-329-3p directly interacted with XIST or CREB1 in glioma. In addition, miR-329-3p inhibitor abolished XIST silencing-induced regulatory effects on cell proliferation, apoptosis, invasion, and radio-sensitivity. Meanwhile, miR-329-3p inhibitor counteracted CREB1 silencing-induced inhibition on cell progression and facilitation on radio-sensitivity in glioma. Moreover, we found that XIST could increase CREB1 expression by sponging miR-329-3p. Animal experiments revealed that XIST silencing restrained tumor growth in vivo. CONCLUSIONS: XIST accelerates cell proliferation, invasion and inhibits cell apoptosis by repressing radio-sensitivity of glioma via enhancing CREB1 expression through sponging miR-329-3p, representing prospective methods for glioma treatment.

Review paper: Implications of the "cancer stem cell" hypothesis on murine models of colon cancer and colitis-associated cancer.

The use of murine models to investigate human diseases has been an invaluable tool. In the areas of inflammation and oncogenesis, such models have provided unique insights into pathogenesis and mechanisms to evaluate potential therapy. As such, one facet of these disease processes links inflammation and cancer. Inflammation is associated with at least 15% of the world's malignancies. One example of this relationship is documented in the association between colitis and colorectal cancer. To date, the precise molecular events linking inflammation and cancer remain unclear. A new paradigm that may bridge these processes includes the cancer stem cell hypothesis. In this review, murine models of colitis, colon cancer, and colitis-associated cancer are discussed in reference to the potential of this paradigm to clarify the relationship of these devastating diseases.

Over-expression of DJ-1 attenuates effects of curcumin on colorectal cancer cell proliferation and apoptosis.

OBJECTIVE: The phosphatase and tensin homologue deleted on chromosome ten (PTEN) acts as a tumor suppressor gene by inhibiting the phosphatidylinositol 3-kinase/protein kinase B (PI3K/AKT) signaling pathway. DJ-1, a negative regulator of PTEN, is associated with the pathogenesis of a variety of tumors. Curcumin (Cur) is a phenolic compound that is extracted from various plant rhizomes with various anti-tumor pharmacological effects. This study aimed to investigate the effects of Cur on proliferation and apoptosis of colorectal cancer cells. MATERIALS AND METHODS: Human normal colorectal epithelial cell line (NCM460) and colorectal cancer cell line (SW480 and SW620) were cultured in vitro. Real-time quantitative PCR (RT-PCR) and western blot were used to detect DJ-1 and PTEN mRNA and protein, respectively. Cell apoptosis was determined with flow cytometry. SW480 cells were divided into control, 20 µM Cur treatment group, Cur+pcDNA3.1-Blank group and Cur+pcDNA3.1-DJ-1 group. Cell proliferation activity was evaluated with EdU staining. RESULTS: Comparing with NCM460 cells, DJ-1 was significantly increased, while PTEN was significantly declined in SW480 and SW620 cells (p<0.05). Cur treatment significantly inhibited SW480 and SW620 cell proliferation and significantly induced apoptosis compared to control group (p<0.05) but showed no significant effects on NCM460 cells. Cur down-regulated DJ-1 level and enhanced PTEN expressions in SW480 cells with dose dependence. The pcDNA3.1-DJ-1 transfection significantly declined PTEN expression, enhanced p-AKT levels, reduced cell apoptosis, and strengthened cell proliferation in SW480 cells treated by Cur (p<0.05). CONCLUSIONS: Cur can inhibit colorectal cancer cell proliferation and promote apoptosis by down-regulating DJ-1 expression to regulate the activity of PTEN/PI3K/AKT signaling pathway.

Isolation of protein glycosylation mutants in the fission yeast Schizosaccharomyces pombe.

We have isolated mutants in the fission yeast Schizosaccharomyces pombe that are defective in protein glycosylation. A collection of osmotically sensitive mutants was prepared and screened for glycosylation defects using lectin staining as an assay. Mutants singly defective in four glycoprotein synthesis genes (gps1-4) were isolated, all of which bind less galactose-specific lectin. Acid phosphatase and other glycoproteins from the gps mutants have increased electrophoretic mobility, suggesting that these mutants make glycans of reduced size. N-linked glycan analysis revealed that terminal oligosaccharide modification is defective in the gps1 and gps2 mutants. Both mutants synthesize the Man9GlcNAc2 core glycan but have reduced amounts of larger structures. Modified core glycans from gps1 cells have normal amounts of galactose (Gal) residues, but reduced amounts of Man, consistent with a defect in a Golgi mannosyltransferase in this mutant. In contrast, N-linked oligosaccharides from gps2 mutants have much less Gal than wild type, because of reduced levels of the Gal donor, UDP-Gal. This reduction is caused by decreased activity of UDP-glucose 4-epimerase, which synthesizes UDP-Gal. Neither the gps1 or gps2 mutations are lethal, although the cells grow at reduced rates. These findings suggest that S. pombe cells can survive with incompletely glycosylated cell wall glycoproteins. In particular, these results suggest that Gal, which comprises approximately 30% by weight of cell wall glycoprotein glycans, is not crucial for cell growth or survival.

Oct-1 binds promoter elements required for transcription of the GnRH gene.

The GnRH gene is exclusively expressed in a discrete population of neurons in the hypothalamus. The promoter-proximal 173 bp of the rat GnRH gene are highly conserved through evolution and are bound by multiple nuclear proteins found in the neuronal cell line, GT1-7, a model for the GnRH-expressing hypothalamic neuron. To explore the protein-DNA interactions that occur within this promoter and the role of these interactions in targeting GnRH gene expression, we have mutagenized individual binding sites in this region. Deoxyribonuclease I protection experiments reveal that footprint 2, a 51-bp sequence that confers a 20-fold induction of the GnRH gene, is comprised of at least three independent protein-binding sites. Transfections of the GnRH promoter-reporter plasmid containing a series of block mutations of footprint 2 into GT1-7 neurons indicate that each of the three putative component sites contributes to transcriptional activity. Mutations in footprint 4 also decrease GnRH gene expression. Footprint 4 and the promoter-proximal site in footprint 2 contain octamer-like motifs, an element that is also present in the neuron-specific enhancer of the rat GnRH gene located approximately 1.6 kb upstream of the promoter. Previous studies in our laboratory have demonstrated that two enhancer octamer sites are bound by the POU-homeodomain transcription factor Oct-1 in GT1-7 cells. We now show that Oct-1 binds the octamer motifs within footprints 2 and 4. Thus, Oct-1 plays a critical role in the regulation of GnRH transcription, binding functional elements in both the distal enhancer and the promoter-proximal conserved region.

DNA flow cytometric analysis of human nasopharyngeal carcinoma in nude mice.

The tissue from a patient with nasopharyngeal carcinoma has been transferred to nude mice (BALB/c), and has successfully been growing through twenty passages. The tumors in the nude mice and primary human tumor have been examined for the cellular DNA content by FCM and also conventional pathological examination, chromosome analysis, and EBV test. The tumor take rate varied markedly in different passages with a mean value of approximately 70%, and showing a tendency to increase. The tumor doubling time within 6-12 weeks after transplantation of six tumors in 18 and 20 passages were 14.8 and 9.3 days respectively. However, the tumor volume at 12 weeks varied significantly, ranging from 438 to 1998 mm3. By FCM, it has been found that the values of DNA index were about the same in both primary tumor and the tumors in nude mice. The distribution of various phase cells in cell cycle was also about the same in both. In conclusion, the application of FCM to examine the cellular DNA content of the tumor in nude mice is a rapid and sensitive method, useful in the investigation on the stability of biological characteristics of human NPC in nude mice and in further studies on the effects by various therapeutic methods.

Agenesis of the internal carotid artery associated with neurofibromatosis type II.

We report a case of agenesis of the internal carotid artery associated with neurofibromatosis type II. Common carotid arteriograms showed no visualization of the internal carotid artery. CT revealed absence of the corresponding carotid canal. MR documented absence of the internal carotid artery in the cavernous sinus.

Diaschisis in chronic viral encephalitis with Koshevnikov syndrome.

The authors report a 61-year-old man with chronic viral encephalitis and Koshevnikov syndrome occurring 42 months after initial symptom of right hemiparesis. Serial computed tomography of the brain showed changes in the attenuation of the left temporal lobe lesion over time. Magnetic resonance images of the brain showed enlargement of left temporoparietooccipital lobes with cortical gyral enhancement on T1-weighted images following intravenous administration of gadolinium-DTPA. 99mTc-HMPAO single-photon emission computerized tomography showed increased radioactivity and hyperperfusion in the left temporoparietal region with paradoxically decreased local tissue perfusion at the contralateral right hemisphere. Follow-up magnetic resonance images of the brain 4 years later showed atrophy of bilateral cerebral hemispheres. We postulate that a "transcallosal diaschisis" with subsequent degeneration is a possible mechanism. A brain biopsy from the left temporal lobe lesion showed pictures compatible with viral encephalitis probably herpes simplex encephalitis.

Cerebral venous thrombosis in patients with nephrotic syndrome--case reports.

The authors describe two cases of cerebral venous thrombosis (CVT) in patients with nephrotic syndrome. The main clinical features of CVT were persistent headache, hemiparesis, and seizure, and the diagnosis was based on magnetic resonance imaging and magnetic resonance angiography. Both showed acquired deficiency of free protein S. The neurologic symptoms remained stationary in the first patient, who received no anticoagulation therapy, but resolved rapidly in the second, treated with intravenous heparin and supplemented with fresh frozen plasma. CVT should be suspected in patients with nephrotic syndrome who present with symptoms of intracranial hypertension or any focal neurologic deficit.

Early diagnosis of single segment vertebral osteomyelitis--MR pattern and its characteristics.

Nine cases of single segment vertebral osteomyelitis were included based on the single level of vertebral body involvement according to the MR findings. They were 3 cases with tuberculous infection and 6 cases with pyogenic infection. The vertebral body involvement was presented as abnormal signal changes (100%) and heterogenous enhancement (77.7%). They usually caused the cortical disruption in its anterior aspect (100%). It goes along the upward subligamentous spread (100%) most often, then the upper disc involvement (66.6%) and downward subligamentous spread (55.5%). The lower disc involvement is least common (11.1%). By using these criteria, the single segment vertebral osteomyelitis could be earlier diagnosed.

MRI appearance of spinal lesions: metastatic tumors or infections?

Three patients with pathologically verified spinal osteomyelitis and another three with metastatic tumors of the spine were investigated. MRI of th spine of four patients showed several unusual findings. The preservation of intervertebral discs and endplates did not predict accurately the diagnosis of either infections or tumors. The "pepper and salt" appearing feature may also occur in a metastatic tumor. Plain radiographs, CT, and radioisotope bone scans were less sensitive than MRI to disclose the lesions. In cases of osteomyelitis, the systemic sources of infections were frequently not found, and the responsible microorganisms could not be identified even from the surgical specimens of two patients. However, mycobacterium tuberculosis was found in the surgical specimen of a patient with cervical spinal lesion whose MRI was indistinguishable from a metastatic tumor. Surgicopathological diagnosis was therefore crucial and mandatory in these instances.

Computed tomography of the brain in patients with serum prolactin levels over 200 ng/ml.

We reviewed the computed tomographic (CT) findings of the sella turcica in 26 patients with a serum prolactin level of over 200 ng/ml. The interval between the dates of CT examination and checking of the serum prolactin level were within 2 months. There were 24 nonpregnant women with a mean age of 30 years and 2 men with a mean age of 28.5 years. None of them were taking medication known to cause an elevation in serum prolactin levels. Surgery was performed on 8 patients with chromophobe adenomas of the pituitary gland: 6 of them were proven to have prolactin-secreting tumors (prolactinomas) after performing a special stain, and the remaining 2 patients, clinically diagnosed as prolactinomas, showed extremely high serum prolactin levels (3,200 and 2,251 ng/ml, respectively). CT studies showed that the height of the pituitary gland in the coronal sections were more than 7 mm in 15 cases (58%) and more than 10 mm in 13 cases (50%); focal bulging of the diaphragma sellae in 16 cases (62%); erosion of the sellar floor in 20 cases (77%); deviation of the pituitary stalk in 19 cases (73%); and abnormal attenuation or enhancement of the pituitary gland in 18 cases (69%). Three patients (12%) showed no evidence of any abnormal CT finding despite a hyperprolactinemic state of over 200 ng/ml. Six histologically proven cases (23%) of prolactinomas and chromophobe adenomas showed radiologic evidence of cavernous sinus invasion. We conclude that patients with a serum prolactin level higher than 200 ng/ml generally show significant changes in the sella turcica in CT.

Diagnosis of cardiac metastasis by computed tomography: report of 5 cases.

Five patients with underlying malignancy were detected antemortemly to have cardiac metastasis by post-enhanced CT scanning. The most common presentations were abnormal heart sounds, electrocardiographic changes and inexplicable heart failure; which lead us to suspect cardiac metastasis. One patient had an "engorged azygous knob" on his chest x-ray film, which provided a clue to possible cardiac metastasis. All of these patients had tumor thrombi in their large tributary veins in addition to the primary tumors. Thus, we advanced the CT scan to the cardiac region and cardiac metastases were, therefore, diagnosed. The tumor thrombi in the large tributary veins seemed to be the source for intracardiac spreading. Cardiac angiographies were performed in 3 patients and confirmed the diagnosis. We conclude that post-enhanced CT scanning is useful in the diagnosis of cardiac metastasis and the presence of tumor thrombi in the large tributary vein is an early sign of cardiac involvement.

CT myelography for differential diagnosis between intramedullary and intradural-extramedullary spinal tumors in the region of the conus medullaris.

We reviewed the myelograms and computed tomographic myelograms of 12 cases of intraspinal tumor with a "cupping sign" on the myelogram in the region of the conus medullaris from 1986 to 1988. There were 5 intramedullary tumors, 4 of them having an exophytic component, and 7 intradural-extramedullary tumors. The myelograms revealed that 4 of the 5 intramedullary tumors showed expansion and the outline of the conus medullaris was irregular, whereas 1 of the tumors showed smooth compression (crescent-shaped) and displacement of the conus medullaris. Six of the 7 intradural-extramedullary tumors showed smooth compression and displacement of the conus medullaris, while 1 of the tumors had caused expansion of the conus medullaris. Complete blockage of the passage of the contrast medium was noted in 3 of the 5 intramedullary tumors, while a partial block was noted in 3 of the 7 intradural-extramedullary tumors. Two of the 7 intradural-extramedulllary tumors showed an extradural tumor component, such as a dumb-bell tumor and a enlarged intervertebral neural foramen. Tumor calcification was noted in 1 of the 7 intradural-extramedullary tumors. Dural ectasia was noted in 2 of the 7 intradural-extramedullary tumors which were later proven to be neurofibromatosis. We conclude that smooth compression (crescent-shaped) and displacement of the conus medullaris, existence of an extradural tumor component, and eroded intervertebral neural foramina favor intradural-extramedullary tumors, while expansion and a conus medullaris with an irregular outline favors intramedullary tumors.

Burkitt's and non-Burkitt's type lymphoma: clinicopathological and radiological manifestations.

Nine cases of Burkitt's type and 5 case of non-Burkitt's type small, non-cleaved cell lymphoma were retrospectively studied to evaluate their clinical and radiological manifestations. In the Burkitt's group, the median age of onset was 9 years old; the male to female ratio was 2:1; and the most frequent presentation was abdominal mass. These features conformed to those of non-endemic (or American) type Burkitt's lymphoma. In comparison with the Burkitt's group, less male-predominance (M:F = 2:3) and cervical mass as the most frequent initial symptom were found in the non-Burkitt's group. Plain films and computed tomographies were collected to evaluate the encroachment of the disease into various organs or compartments. There was a statistically significant correlation in site of the main mass between these two types; the Burkitt's type prefers extranodal, whereas the non-Burkitt's type prefers nodal, involvement. Computed tomographic appearance of Burkitt's lymphoma was also analyzed and summarized by the following five aspects: (1) tumor location-predominantly in the abdomen or head/neck region; (2) tumor density-rather homogeneous and slightly less than that of muscle; (3) tumor margin-often well-localized with distinct contrast to adjacent normal tissue; (4) extranodal predilection- the most frequent pattern of involvement; and (5) bony chang-often mild, despite the size of the mass.

Predictive value of total body bone mineral density for vertebral fractures in elderly women. Geriatric Study Group.

In a general population-based geriatric disease survey in Taipei City, the bone mineral density (BMD) of 58 women over 65 years of age was measured for the whole body, lumbar spine (L2-L4), and proximal femurs using a 153Gd based dual photon absorptiometer. These women were found to have at least one vertebral fracture. The results showed that the BMD readings of both the lumbar spine (L2-L4) (mean Z score +/- SEM = 0.05 +/- 0.12) and the femoral neck (mean Z score +/- SEM = -0.20 +/- 0.10) were not statistically different from those of age-matched controls. However, the total body BMD in these 58 patients was significantly lower than in the normal controls (mean Z score +/- SEM = -1.07 +/- 0.10, p < 0.0001). In the normal control group (N = 69, age 50-85), there was a significant linear correlation between the total body and lumbar BMD (r = 0.81, p < 0.0001). This correlation was not found in the 58 women with vertebral fractures (r = 0.14, NS). Our results suggest that geriatric women with vertebral fractures are more osteoporotic than normal aged women, even though they have a relatively mild degree of spinal osteoporosis. But, because of age-associated degenerative changes or other factors, conventional anteroposterior lumbar BMD measurements cannot detect the difference. The total body BMD readings, but not the lumbar or femoral neck BMD readings, seem to be less affected by these local changes and may provide a better discriminative or predictive value for vertebral fracture in this particular age group.

Hemorrhage in intracranial epidermoid cyst.

A case of intracranial epidermoid cyst with intracystic hemorrhage is reported. A 63-year-old woman sustained a head injury after a fall; obtundation and ataxia were noted later. Computed tomography revealed a heterogeneous hyperdense lesion in the posterior and middle cranial fossas. Magnetic resonance imaging showed a lesion with increased signal intensity both on T1 and T2 weighted images. Two craniotomies revealed an intracranial epidermoid cyst with about 6 mL of clotted blood. Pathologic study showed hemosiderin-laden macrophages and neovascularity in the cystic wall granulation tissue, which indicated rupture of the cystic wall with intracystic hemorrhage, which later correlated with the diagnostic image findings. The patient tolerated the two operations well and her postoperative course was smooth. She was discharged in good health without obvious neurologic deficits.