Prophylaxis for paediatric emergence delirium in desflurane-based anaesthesia: a network meta-analysis.

PURPOSE: The prevalence of postoperative emergence delirium in paediatric patients (pedED) following desflurane anaesthesia is considerably high at 50-80%. Although several pharmacological prophylactic strategies have been introduced to reduce the risk of pedED, conclusive evidence about the superiority of these individual regimens is lacking. The aim of the current study was to assess the potential prophylactic effect and safety of individual pharmacotherapies in the prevention of pedED following desflurane anaesthesia. METHODS: This frequentist model network meta-analysis (NMA) of randomized controlled trials (RCTs) included peer-reviewed RCTs of either placebo-controlled or active-controlled design in paediatric patients under desflurane anaesthesia. RESULTS: Seven studies comprising 573 participants were included. Overall, the ketamine + propofol administration [odds ratio (OR) = 0.05, 95% confidence intervals (95%CIs) 0.01-0.33], dexmedetomidine alone (OR = 0.13, 95%CIs 0.05-0.31), and propofol administration (OR = 0.30, 95%CIs 0.10-0.91) were associated with a significantly lower incidence of pedED than the placebo/control groups. In addition, only gabapentin and dexmedetomidine were associated with a significantly higher improvement in the severity of emergence delirium than the placebo/control groups. Finally, the ketamine + propofol administration was associated with the lowest incidence of pedED, whereas gabapentin was associated with the lowest severity of pedED among all of the pharmacologic interventions studied. CONCLUSIONS: The current NMA showed that ketamine + propofol administration was associated with the lowest incidence of pedED among all of the pharmacologic interventions studied. Future large-scale trials to more fully elucidate the comparative benefits of different combination regimens are warranted. TRIAL REGISTRATION: PROSPERO CRD42021285200.

Effects of bihemispheric transcranial direct current stimulation on motor recovery in subacute stroke patients: a double-blind, randomized sham-controlled trial.

BACKGROUND: Bihemispheric transcranial direct current stimulation (tDCS) of the primary motor cortex (M1) can simultaneously modulate bilateral corticospinal excitability and interhemispheric interaction. However, how tDCS affects subacute stroke recovery remains unclear. We investigated the effects of bihemispheric tDCS on motor recovery in subacute stroke patients. METHODS: We enrolled subacute inpatients who had first-ever ischemic stroke at subcortical regions and moderate-to-severe baseline Fugl-Meyer Assessment of Upper Extremity (FMA-UE) score 2-56. Participants between 14 and 28 days after stroke were double-blind, randomly assigned (1:1) to receive real (n = 13) or sham (n = 14) bihemispheric tDCS (with ipsilesional M1 anode and contralesional M1 cathode, 20 min, 2 mA) during task practice twice daily for 20 sessions in two weeks. Residual integrity of the ipsilesional corticospinal tract was stratified between groups. The primary efficacy outcome was the change in FMA-UE score from baseline (responder as an increase ≥ 10). The secondary measures included changes in the Action Research Arm Test (ARAT), FMA-Lower Extremity (FMA-LE) and explorative resting-state MRI functional connectivity (FC) of target regions after intervention and three months post-stroke. RESULTS: Twenty-seven participants completed the study without significant adverse effects. Nineteen patients (70%) had no recordable baseline motor-evoked potentials (MEP-negative) from the paretic forearm. Compared with the sham group, the real tDCS group showed enhanced improvement of FMA-UE after intervention (p < 0.01, effect size η2 = 0.211; responder rate: 77% vs. 36%, p = 0.031), which sustained three months post-stroke (p < 0.01), but not ARAT. Interestingly, in the MEP-negative subgroup analysis, the FMA-UE improvement remained but delayed. Additionally, the FMA-LE improvement after real tDCS was not significantly greater until three months post-stroke (p < 0.01). We found that the individual FMA-UE improvements after real tDCS were associated with bilateral intrahemispheric, rather than interhemispheric, FC strengths in the targeted cortices, while the improvements after sham tDCS were associated with predominantly ipsilesional FC changes after adjustment for age and sex (p < 0.01). CONCLUSIONS: Bihemispheric tDCS during task-oriented training may facilitate motor recovery in subacute stroke patients, even with compromised corticospinal tract integrity. Further studies are warranted for tDCS efficacy and network-specific neuromodulation. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov: (ID: NCT02731508).

Orthostatic myoclonus - A retrospective study of Asian patients.

BACKGROUND/PURPOSE: Orthostatic myoclonus (OM) is myoclonic jerks in both legs during standing. It may relate to gait unsteadiness and may be associated with various diagnoses, including neurodegenerative, systemic, and musculoskeletal diseases. Diagnosis is based on the surface electromyography (SEMG). METHODS: From January 2016 to June 2020, we retrospectively reviewed 35 patients diagnosed with OM based on the SEMG criteria and analyzed the electrophysiological data. RESULTS: The mean age was 75.3±8.9. Disease duration ranged from 2 days to several years. Genders were equally affected. The most common symptom was gait disturbance, and the next was leg tremulous sensation, followed by backward disequilibrium. 28.6% of our patients had falls. Electrophysiologically, bursting duration shorter than 100 ms supported the myoclonic origin from the cortex. The bursting activity occurred only on the upright and weight-bearing leg. The associated diagnoses included lumbosacral radiculopathy (28.6%), lumbosacral radiculopathy plus myasthenia gravis (2.9%), lumbosacral radiculopathy plus vascular parkinsonism (5.7%), diabetic polyneuropathy (5.7%), vascular parkinsonism (17.1%), Parkinson's disease (PD) (14.2%), normal pressure hydrocephalus (5.7%), medication-induced parkinsonism (2.9%), cervical myelopathy (2.9%), medication-related myoclonus (2.9%), and unknown (11.4%). In PD, OM was present before, along with, or after PD diagnosis. The myoclonic activity disrupted the parkinsonian tremor upon standing on SEMG. CONCLUSION: OM is a syndrome instead of a diagnosis. It is more prevalent in the elderly with gait disturbance and patients will not necessarily fall. It is associated with central and peripheral nerve system disorders, systemic diseases, and medication use. We hypothesize that OM is a pathological disintegration of motor circuit.

Comparison of nerve conduction study and transcranial magnetic stimulation for early diagnosis and prognosis prediction of idiopathic facial palsy.

OBJECTIVE: Multiple electrophysiologic studies have been conducted in the evaluation of facial neuropathy. In our study, the diagnostic and prognostic values of nerve conduction studies (NCSs) and transcranial magnetic stimulation (TMS) were compared for idiopathic unilateral facial neuropathy. METHOD: We recruited patients with newly diagnosed idiopathic unilateral facial neuropathy and performed a blink reflex test, facial NCSs, and TMS. The amplitude of facial compound muscle action potential (CMAP) and motor evoked potential (MEP) between the affected and unaffected sides of the face was compared. RESULT: A total of 30 patients were enrolled in the final analysis. TMS yielded a better detection rate, and MEP reduction rate was significantly higher than CMAP reduction rate, early in the course of the disease. Poor prognosis was positively associated with the CMAP reduction rate. The cutoff value of the CMAP reduction rate in the prediction of poor prognosis was established as 0.42. CONCLUSION: Facial TMS could detect idiopathic unilateral facial neuropathy with a high sensitivity when used as an early diagnostic tool. Facial NCS could predict prognosis, and the CMAP reduction rate was significantly associated with poor short-term prognosis.

Neurophysiological signatures of hand motor response to dual-transcranial direct current stimulation in subacute stroke: a TMS and MEG study.

BACKGROUND: Dual transcranial direct current stimulation (tDCS) to the bilateral primary motor cortices (M1s) has potential benefits in chronic stroke, but its effects in subacute stroke, when behavioural effects might be expected to be greater, have been relatively unexplored. Here, we examined the neurophysiological effects and the factors influencing responsiveness of dual-tDCS in subacute stroke survivors. METHODS: We conducted a randomized sham-controlled crossover study in 18 survivors with first-ever, unilateral subcortical ischaemic stroke 2-4 weeks after stroke onset and 14 matched healthy controls. Participants had real dual-tDCS (with an ipsilesional [right for controls] M1 anode and a contralesional M1 [left for controls] cathode; 2 mA for 20mins) and sham dual-tDCS on separate days, with concurrent paretic [left for controls] hand exercise. Using transcranial magnetic stimulation (TMS) and magnetoencephalography (MEG), we recorded motor evoked potentials (MEPs), the ipsilateral silent period (iSP), short-interval intracortical inhibition, and finger movement-related cortical oscillations before and immediately after tDCS. RESULTS: Stroke survivors had decreased excitability in ipsilesional M1 with a relatively excessive transcallosal inhibition from the contralesional to ipsilesional hemisphere at baseline compared with controls, as quantified by decreased MEPs and increased iSP duration. Dual-tDCS led to increased MEPs and decreased iSP duration in ipsilesional M1. The magnitude of the tDCS-induced MEP increase in stroke survivors was predicted by baseline contralesional-to-ipsilesional transcallosal inhibition (iSP) ratio. Baseline post-movement synchronization in α-band activity in ipsilesional M1 was decreased after stroke compared with controls, and its tDCS-induced increase correlated with upper limb score in stroke survivors. No significant adverse effects were observed during or after dual-tDCS. CONCLUSIONS: Task-concurrent dual-tDCS in subacute stroke can safely and effectively modulate bilateral M1 excitability and inter-hemispheric imbalance and also movement-related α-activity.

Peroxisome Proliferator-Activated Receptor γ Coactivator 1α Activates Vascular Endothelial Growth Factor That Protects Against Neuronal Cell Death Following Status Epilepticus through PI3K/AKT and MEK/ERK Signaling.

Status epilepticus may cause molecular and cellular events, leading to hippocampal neuronal cell death. Peroxisome proliferator-activated receptor γ coactivator 1-α (PGC-1α) is an important regulator of vascular endothelial growth factor (VEGF) and VEGF receptor 2 (VEGFR2), also known as fetal liver kinase receptor 1 (Flk-1). Resveratrol is an activator of PGC-1α. It has been suggested to provide neuroprotective effects in epilepsy, stroke, and neurodegenerative diseases. In the present study, we used microinjection of kainic acid into the left hippocampal CA3 region in Sprague Dawley rats to induce bilateral prolonged seizure activity. Upregulating the PGC-1α pathway will increase VEGF/VEGFR2 (Flk-1) signaling and further activate some survival signaling that includes the mitogen activated protein kinase kinase (MEK)/mitogen activated protein kinase (ERK) and phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT) signaling pathways and offer neuroprotection as a consequence of apoptosis in the hippocampal neurons following status epilepticus. Otherwise, downregulation of PGC-1α by siRNA against pgc-1α will inhibit VEGF/VEGFR2 (Flk-1) signaling and suppress pro-survival PI3K/AKT and MEK/ERK pathways that are also accompanied by hippocampal CA3 neuronal cell apoptosis. These results may indicate that the PGC-1α induced VEGF/VEGFR2 pathway may trigger the neuronal survival signaling, and the PI3K/AKT and MEK/ERK signaling pathways. Thus, the axis of PGC-1α/VEGF/VEGFR2 (Flk-1) and the triggering of downstream PI3K/AKT and MEK/ERK signaling could be considered an endogenous neuroprotective effect against apoptosis in the hippocampus following status epilepticus.

Responsiveness of the short-form health survey and the Parkinson's disease questionnaire in patients with Parkinson's disease.

BACKGROUND: The responsiveness of a measurement instrument is important for understanding its ability to detect changes in the progression of a disease. We examined and compared the internal and external responsiveness of the 36-item Short-Form Health Survey (SF-36) and the 39-item Parkinson's Disease Questionnaire (PDQ-39) in patients with Parkinson's Disease (PD). METHODS: Seventy-four patients with PD were evaluated using the SF-36 and PDQ-39 at baseline and again after one year. In addition, their motor signs, motor difficulties of daily living, and depressive symptoms were assessed as external criteria. The internal responsiveness was examined using effect size, standardized response mean, and the Wilcoxon signed rank test. The external responsiveness was examined using receiver operating characteristic curves, correlation analyses, and regression models. RESULTS: Both instruments were partially sensitive to changes during the 1-year follow-up and able to discriminate between patients with improved versus deteriorated motor signs. In addition, both were similarly responsive to changes in the motor difficulties of daily living; the SF-36 appeared to be more sensitive than the PDQ-39 to changes in depressive symptoms. CONCLUSIONS: The SF-36 and the PDQ-39 were acceptably internally and externally responsive during the 1-year follow-up.

Cholesterol Levels Are Associated with 30-day Mortality from Ischemic Stroke in Dialysis Patients.

BACKGROUND: We investigated the impact of serum cholesterol levels on 30-day mortality after ischemic stroke in dialysis patients. METHODS: From the Taiwan Stroke Registry data, we identified 46,770 ischemic stroke cases, including 1101 dialysis patients and 45,669 nondialysis patients from 2006 to 2013. RESULTS: Overall, the 30-day mortality was 1.46-fold greater in the dialysis group than in the nondialysis group (1.75 versus 1.20 per 1000 person-days). The mortality rates were 1.64, .62, 2.82, and 2.23 per 1000 person-days in dialysis patients with serum total cholesterol levels of <120 mg/dL, 120-159 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively. Compared to dialysis patients with serum total cholesterol levels of 120-159 mg/dL, the corresponding adjusted hazard ratios of mortality were 4.20 (95% confidence interval [CI] = 1.01-17.4), 8.06 (95% CI = 2.02-32.2), and 6.89 (95% CI = 1.59-29.8) for those with cholesterol levels of <120 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively. CONCLUSIONS: Dialysis patients with serum total cholesterol levels of ≥160 mg/dL or <120 mg/dL on admission are at an elevated hazard of 30-day mortality after ischemic stroke.

Effective and Cheap Behavioral Modification Therapy to Manage Complicated Polydipsia and Seizures in a Chronic Mental Health Institute.

PURPOSE: Polydipsia is one of the most serious and complicated problems causing morbidity and mortality in chronic mental health institutes. The pathophysiology of polydipsia in chronic schizophrenia remains unclear; as a result, no effective methods exist to deal with this serious problem. This report describes a patient with schizophrenia with polydipsia and seizures who benefitted from a behavioral modification program at a chronic mental health institute. CASE REPORT: A 56-year-old schizophrenic man did not have a history of physical illnesses or seizures and developed seizures following polydipsia. Despite drug adjustment, his polydipsia was uncontrolled and he suffered from generalized tonic convulsions. After introducing a "water restriction program," his polydipsia and seizures were controlled. CONCLUSION: The "water restriction program" consisted of daily body weight monitoring and frequent checking of electrolyte data, both of which are inexpensive and simple. This program can be carried out by untrained nursing staff, who are the primary caregivers in chronic mental health institutes. Our case highlights an effective and inexpensive behavior modification program to deal with the difficult and complicated problems of polydipsia and seizures in chronic mental health institutes.

Derivation and validation of a discharge disposition predicting model after acute stroke.

BACKGROUND: Discharge disposition planning is vital for poststroke patients. We investigated clinical factors associated with discharging patients to nursing homes, using the Taiwan Stroke Registry data collected from 39 major hospitals. METHODS: We randomly assigned 21,575 stroke inpatients registered from 2006 to 2008 into derivation and validation groups at a 3-to-1 ratio. We used the derivation group to develop a prediction model by measuring cumulative risk scores associated with potential predictors: age, sex, hypertension, diabetes mellitus, heart diseases, stroke history, snoring, main caregivers, stroke types, and National Institutes of Health Stroke Scale (NIHSS). Probability of nursing home care and odds ratio (OR) of nursing home care relative to home care by cumulative risk scores were measured for the prediction. The area under the receiver operating characteristic curve (AUROC) was used to assess the model discrimination against the validation group. RESULTS: Except for hypertension, all remaining potential predictors were significant independent predictors associated with stroke patient disposition to nursing home care after discharge from hospitals. The risk sharply increased with age and NIHSS. Patients with a cumulative risk score of 15 or more had an OR of 86.4 for the nursing home disposition. The AUROC plots showed similar areas under curves for the derivation group (.86, 95% confidence interval [CI], .85-.87) and for the validation group (.84, 95% CI, .83-.86). CONCLUSIONS: The cumulative risk score is an easy-to-estimate tool for preparing stroke patients and their family for disposition on discharge.

Intracranial Hypotension as A Rare Complication of Vertebroplasty: A Case Report.

BACKGROUND: Vertebral compression fracture is one of the frequent complications of osteoporosis. Percutaneous vertebroplasty (PVP) has been applied in the treatment of osteoporotic vertebral compression fractures, multiple myelomas and vertebral metastatic lesions. Complications of the procedure include bleeding at the puncture site, local infection, cement leakage in the vertebral canal and intervertebral foramen. Cerebrospinal fluid leakage after the procedure was rarely mentioned in the literature. CASE REPORT: A 51-year-old healthy female patient has no neurologic or orthopedic illness before. She suffered from severe low back pain since 10 days ago after some exercise. She has back pain with radiating to bilateral subcostal areas. The pain aggravated by bending forward. X ray of spine showed T12 vertebral body compression fracture. MRI demonstrated compression fracture at T12 with bone marrow edema and increased bone marrow enhancement. Bone mineral density checked by Dualenergy X-ray absorptiometry revealed osteopenia. The symptoms were not relieved by conservative treatments and she received vertebroplasty for pain relief. The operation course was smooth, but she started to suffer from orthostatic headache after the procedure. Spinal MRI revealed fluid accumulation at posterior epidural space of T11-12-L1 and CSF leakage was impressed. Intracranial hypotension related to CSF leakage was diagnosed according to the Diagnostic criteria formulated by Schievink, et al (2008). After hydration and bed-rest, her symptoms improved gradually without epidural blood patch. CONCLUSION: Our report highlights the possibility and importance of intracranial hypotension related to CSF leakage after vertebroplasty. Clinicians should be alert to this complication.

Post-stroke upper limb recovery is correlated with dynamic resting-state network connectivity.

Motor recovery is still limited for people with stroke especially those with greater functional impairments. In order to improve outcome, we need to understand more about the mechanisms underpinning recovery. Task-unbiased, blood flow-independent post-stroke neural activity can be acquired from resting brain electrophysiological recordings and offers substantial promise to investigate physiological mechanisms, but behaviourally relevant features of resting-state sensorimotor network dynamics have not yet been identified. Thirty-seven people with subcortical ischaemic stroke and unilateral hand paresis of any degree were longitudinally evaluated at 3 weeks (early subacute) and 12 weeks (late subacute) after stroke. Resting-state magnetoencephalography and clinical scores of motor function were recorded and compared with matched controls. Magnetoencephalography data were decomposed using a data-driven hidden Markov model into 10 time-varying resting-state networks. People with stroke showed statistically significantly improved Action Research Arm Test and Fugl-Meyer upper extremity scores between 3 weeks and 12 weeks after stroke (both P < 0.001). Hidden Markov model analysis revealed a primarily alpha-band ipsilesional resting-state sensorimotor network which had a significantly increased life-time (the average time elapsed between entering and exiting the network) and fractional occupancy (the occupied percentage among all networks) at 3 weeks after stroke when compared with controls. The life-time of the ipsilesional resting-state sensorimotor network positively correlated with concurrent motor scores in people with stroke who had not fully recovered. Specifically, this relationship was observed only in ipsilesional rather in contralesional sensorimotor network, default mode network or visual network. The ipsilesional sensorimotor network metrics were not significantly different from controls at 12 weeks after stroke. The increased recruitment of alpha-band ipsilesional resting-state sensorimotor network at subacute stroke served as functionally correlated biomarkers exclusively in people with stroke with not fully recovered hand paresis, plausibly reflecting functional motor recovery processes.

High Dosage Omega-3 Fatty Acids Outperform Existing Pharmacological Options for Migraine Prophylaxis: A Network Meta-Analysis.

Migraine is a highly prevalent neurologic disorder with prevalence rates ranging from 9% to 18% worldwide. Current pharmacologic prophylactic strategies for migraine have limited efficacy and acceptability, with relatively low response rates of 40% to 50% and limited safety profiles. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are considered promising therapeutic agents for migraine prophylaxis. The aim of this network meta-analysis (NMA) was to compare the efficacy and acceptability of various dosages of EPA/DHA and other current Food and Drug Administration-approved or guideline-recommended prophylactic pharmacologic interventions for migraine. Randomized controlled trials (RCTs) were eligible for inclusion if they enrolled participants with a diagnosis of either episodic or chronic migraine. All NMA procedures were conducted under the frequentist model. The primary outcomes assessed were 1) changes in migraine frequency and 2) acceptability (i.e., dropout for any reason). Secondary outcomes included response rates, changes in migraine severity, changes in the frequency of using rescue medications, and frequency of any adverse events. Forty RCTs were included (N = 6616; mean age = 35.0 y; 78.9% women). Our analysis showed that supplementation with high dosage EPA/DHA yields the highest decrease in migraine frequency [standardized mean difference (SMD): -1.36; 95% confidence interval (CI): -2.32, -0.39 compared with placebo] and the largest decrease in migraine severity (SMD: -2.23; 95% CI: -3.17, -1.30 compared with placebo) in all studied interventions. Furthermore, supplementation with high dosage EPA/DHA showed the most favorable acceptability rates (odds ratio: 1.00; 95% CI: 0.06, 17.41 compared with placebo) of all examined prophylactic treatments. This study provides compelling evidence that high dosage EPA/DHA supplementation can be considered a first-choice treatment of migraine prophylaxis because this treatment displayed the highest efficacy and highest acceptability of all studied treatments. This study was registered in PROSPERO as CRD42022319577.

A comparison of benign and inflammatory manifestations of Tolosa-Hunt syndrome.

BACKGROUND: Tolosa-Hunt syndrome (THS) manifests as a benign or an inflammatory type disease. The nosography differences between these types remain to be elucidated. We aimed to analyze and compare the clinical presentations of benign and inflammatory THS. METHODS: The ward patients who presented with THS from January 1990 to May 2011 were retrospectively reviewed. THS was diagnosed according to the recommendations of the International Headache Society. RESULTS: Of the 53 THS cases (49 patients), 30 (56.6%) were classified as benign and 23 (43.4%) as inflammatory THS. There were strong similarities between the groups in terms of clinical manifestations, laboratory findings, responses to glucocorticoid treatment, and outcomes. However, patients with inflammatory THS tended to be younger (mean age, 43.4 years; P 0.05) and have optic nerve dysfunction (56.5%; P 0.05) and longer disease duration (2.3 ± 1.0 months; P 0.05) compared to those with benign THS (mean age, 56.4 years; mean disease duration, 1.6 ± 0.7 months). The patients with additional involvement of both the optic nerve and the second division of the trigeminal nerve experienced a longer disease duration ( P 0.05). Additionally, patients with orbital pseudotumors had diplopia that responded poorly to treatment with glucocorticoids ( P 0.05). High-dose (>0.5 mg/kg/day) and low-dose (≤0.5 mg/kg/day) prednisolone were equally effective in relieving symptoms in both groups ( P > 0.05). CONCLUSION: Benign and inflammatory THS were highly similar in terms of nosography. The responses to glucocorticoid treatment were generally good except in patients with orbital pseudotumors.

Sjogren's syndrome with acute cerebellar ataxia and massive lymphadenopathy : a case report.

PURPOSE: Common etiologies of acute acquired cerebellar ataxia include cerebrovascular diseases, toxin or drugs, infections/para-infections, and autoimmune diseases. It is a rare manifestation of Sjögren's syndrome, which is a common autoimmune disease but is often missed as a differential diagnosis. CASE REPORT: This is a report of a patient with acute onset cerebellar ataxia for one month. She also had massive neck lymphadenopathy. After a series of studies and the exclusion of other common causes of acute cerebellar ataxia, she was diagnosed as having Sjögren's syndrome. Patients with Sjögren's syndrome have higher risk for lymphoma, which leads to poorer prognosis. After lymph node biopsy, the patient was proven to have sinus histiocytosis, which is another rare finding in Sjögren's syndrome. DISCUSSION: For patients with acute acquired cerebellar ataxia, immune-mediated cerebellar ataxia should be an important differential diagnosis aside from the more common causes like stroke or drugs.

Treatment, Outcome, and Relapse of Spontaneous and Nonspontaneous Cerebrospinal Fluid Leak.

Cerebrospinal fluid (CSF) leak can be spontaneous or nonspontaneous. The management options include conservative treatments, blood patch, and surgical repairs. We compared clinical symptoms, image findings, management options, hospitalization, and relapse rates among different causes of CSF leaks. Eighty-one patients were recruited: 20 with spontaneous and 61 with nonspontaneous CSF leaks. Nonspontaneous causes included lumbar puncture, surgery, and trauma. Surgery sites comprised sphenoid, spine, skull base, and calvaria. Spontaneous CSF leak came from the sphenoid or spine. Age, gender, body mass index, initial symptoms, hospitalization, treatment courses, and recurrence rates showed no difference between the groups. The spontaneous group had higher CSF accumulations on their MRIs. MRI pachymeninge enhancement showed the highest sensitivity (78.6%) for intracranial hypotension. Meningitis occurred in 1/3 of sphenoid, skull base, and calvarian surgeries. Earlier reoperation was correlated with shorter hospitalization (r = 0.651), but the recurrence rates were similar. Longer intervals between surgery and CSF leak encouraged reoperation. Among the spontaneous spine and lumbar puncture-related CSF leaks, 57.1% of them responded to 4 days of conservative treatment. Among the trauma-related CSF leaks, 90.9% of them required surgical repair. The demographic data and symptoms were similar in various groups of CSF leak. The symptom onset durations and treatment strategies were different. However, the recurrence rates were similar.

Spontaneous dissection of the vertebral artery: report of three cases.

PURPOSE: Vertebral artery dissection (VAD), although uncommon, is an important cause of ischemic stroke in young adults. Without prompt diagnosis and treatment, it may cause mortality and morbidity. Spontaneous VAD related to abrupt neck position change, sudden sneezing, or severe cough and vomiting after fish bone choking are rarely reported. This report describes three cases of spontaneous VAD due to seemingly harmless events. CASE REPORT: The first patient developed vertebro-basilar ischemic symptoms after suddenly turning his head to the left during an argument with a colleague. The second suffered from right lateral medullary infarction after sudden sneezing. The third developed left lateral medullary syndrome after she tried to extract a fish bone in her throat, which induced severe cough and vomiting. The three cases all presented with acute severe neck pain with posterior circulation ischemic symptoms and signs. Magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA), and conventional angiography confirmed the diagnosis. The first patient was treated with warfarin and recovered well. The other two cases received heparinization and then oral anticoagulant therapy, and recovered without residual neurologic deficits. CONCLUSION: In conclusion, VAD should be among the differentials considered when encountering young patients presentation with such clinical symptoms.

Efficacy of pharmacologic treatment in tinnitus patients without specific or treatable origin: A network meta-analysis of randomised controlled trials.

BACKGROUND: Although tinnitus has a prevalence between 20 and 42.8%, the currently recommended management for tinnitus, such as tinnitus support and psychologic therapies, are relatively time-consuming and expensive. Several new pharmacologic treatments designed for tinnitus patients without specific origin had been developed but their efficacy remains unclear. METHODS: The current Network Meta-Analysis (NMA) of randomised controlled trials (RCTs) was conducted to evaluate the efficacy of different pharmacologic treatments for tinnitus management in tinnitus patients without specific or treatable origin (i.e. primary tinnitus). Databases were searched from inception to April 5th, 2021. All network meta-analytic procedures were conducted under the frequentist model. We calculated the effect size of outcomes with different rating scales with standardized mean difference. PROSPERO registration: CRD42020177742. FINDINGS: Overall, 36 RCTs were included with 2,761 participants. The main results revealed that pharmacologic interventions with brain-acting effect (for example, amitriptyline, acamprosate, and gabapentin) and those with anti-inflammation/anti-oxidant effect (for example, intra-tympanic dexamethasone injection plus oral melatonin) were associated with superior improvement in tinnitus severity and response rate compared to placebo/control. Oral amitriptyline were associated with the highest improvement in tinnitus severity and the fourth highest response rate. None of the investigated interventions was associated with different changes in quality of life compared to placebo/control. All the investigated treatments were associated with similar drop-out rate to placebo/control. INTERPRETATION: The current NMA suggests a potential role for treatments with brain-acting effect (for example, amitriptyline, acamprosate, and gabapentin) or anti-inflammation/anti-oxidant effect (for example, intra-tympanic dexamethasone injection plus oral melatonin) as the preferable effective treatments for tinnitus without specific or treatable origin. FUNDING: none.

Renal Function-Dependent Associations of Statins with Outcomes of Ischemic Stroke.

AIM: Chronic kidney disease (CKD) is associated with unfavorable outcomes in patients with ischemic stroke. One major metabolic derangement of CKD is dyslipidemia, which can be managed by statins. This study aimed to investigate whether the association of statins with post-stroke outcomes would be affected by renal function. METHODS: We evaluated the association of statin therapy at discharge with 3-month outcomes according to the estimated glomerular filtration rate (eGFR) of 50,092 patients with acute ischemic stroke from the Taiwan Stroke Registry from August 2006 to May 2016. The outcomes were mortality, functional outcome as modified Rankin Scale (mRS), and recurrent ischemic stroke at 3 months after index stroke. RESULTS: Statin therapy at discharge was associated with lower risks of mortality (adjusted hazard ratio [aHR], 0.41; 95% confidence interval [CI], 0.34 to 0.50) and unfavorable functional outcomes (mRS 3-5; aHR, 0.80; 95% CI, 0.76 to 0.84) in ischemic stroke patients. After stratification by eGFR, the lower risk of mortality associated with statins was limited to patients with an eGFR above 15 mL/min/1.73 m2. Using statins at discharge was correlated with a lower risk of unfavorable functional outcomes in patients with an eGFR of 60-89 mL/min/1.73 m2. Statin therapy in patients with an eGFR of 60-89 mL/min/1.73 m2 may be associated with a higher risk of recurrent ischemic stroke compared with nonusers (aHR, 1.29; 95% CI, 1.07 to 1.57). CONCLUSIONS: In patients with acute ischemic stroke, the associations of statins with mortality and functional outcomes was dependent on eGFR.

Transient attenuation of visual evoked potentials during focal status epilepticus in a patient with occipital lobe epilepsy.

PURPOSE: Seizures originating in the occipital areas are relatively uncommon. They are usually characterized by visual hallucinations and illusions or other symptoms related to the eyes and vision. CASE REPORT: In a 54-year-old woman with occipital lobe epilepsy, complex visual hallucinations, illusions, and migraine-like headache constitute the major clinical manifestations. During focal status epilepticus, ictal electroencephalography revealed rhythmic focal spikes in the right occipital region, rapidly propagating to the right parietal and contralateral occipital areas. Ictal brain single-photon emission computed topography revealed hyperperfusion of the right occipital region. Using a full-field pattern-shift visual evoked potential (VEP) study, we found that the P100 responses on both sides were markedly attenuated in amplitude during occipital focal status epilepticus, whereas the latencies of the VEPs were normal. The amplitude and morphology of P100 responses on both sides, however, returned to the normal range 7 days after cessation of the seizures. CONCLUSION: In addition to clinical seizure semiology, scalp EEG, SPECT and neuroimaging studies, VEP studies may be used as a supplementary examination tool to provide further information in the patients with occipital lobe seizures or epilepsies.