Meralgia paresthetica: Nerve stimulator-guided injection with methylprednisolone/lidocaine, a double-blind randomized placebo-controlled study.

BACKGROUND: Meralgia paresthetica is a mononeuropathy of the lateral femoral cutaneous nerve. A common therapy is injection with corticosteroids. The goal of this study was to analyze the effect of injection with methylprednisolone/lidocaine vs placebo. METHODS: After randomization, 10 patients received a nerve stimulator-guided injection with methylprednisolone/lidocaine, and 10 patients received saline. The primary outcome measure was pain (visual analogue scale, VAS). RESULTS: In the placebo group, there was a significant pain reduction (baseline VAS, 6.8; VAS week 12, 4.3; P = .014). The VAS score in the methylprednisolone group did not show a significant reduction (baseline VAS, 7.4; VAS week 12, 4.8; P = .053). There was no significant difference in pain reduction between the groups. CONCLUSIONS: We found no objective evidence for benefit from nerve stimulator-guided injection with corticosteroids in meralgia paresthetica, although this study is limited by a small sample size. Future placebo-controlled studies using ultrasound-guided injection are warranted.

Predictive value of electroencephalography in anti-NMDA receptor encephalitis.

OBJECTIVES: Anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) is a severe, but treatable disease. This study aims to give a detailed description of electroencephalogram (EEG) results in paediatric and adult patients to improve disease recognition, and analyses the predictive value of the first EEG for the final clinical outcome. METHODS: This nationwide cohort study includes patients with N-methyl-D-aspartate receptor antibodies confirmed with cell-based assay and immunohistochemistry in serum and cerebrospinal fluid. EEG recordings were re-evaluated by two experienced neurophysiologists, mixed with control EEGs for blinding. Initial EEG as well as follow-up registrations were analysed. RESULTS: 35 adults and 18 children were included. Only two patients (4%) had a normal EEG. During the first recording, the majority of the patients had normal posterior rhythm (71%), which was associated with better modified Rankin Scale at final outcome (OR 4.74; 95% CI 1.56 to 14.47; p=0.006). In addition, EEGs showed focal (73%) or diffuse (67%) slowing. The first EEG was severely abnormal in 26%. However, 8 of 14 patients with a severely abnormal first EEG still had a favourable outcome. During the course of the disease, extreme delta brushes (EDBs) were present in 6 of 53(11%)patients. CONCLUSIONS: The first EEG commonly shows normal posterior rhythm with focal or diffuse slowing. Although the sensitivity of an abnormal EEG is high (96%), normal EEG does not exclude anti-NMDARE. EDBs are only present in severely affected patients. The first EEG recording is predictive of the final clinical outcome.

Accuracy of the ice test in the diagnosis of myasthenia gravis in patients with ptosis.

INTRODUCTION: Several studies have reported high diagnostic sensitivity and specificity for the ice test in myasthenia gravis. All of the studies employed a case-control design, in which the diagnosis was already known at the time of the test for both patients and controls, leading to case selection bias. This suggests that the available literature substantially overestimates the diagnostic utility of these tests. METHODS: A retrospective cohort study without selection bias was performed to examine the sensitivity and specificity of the ice test. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the ice test were determined by means of a 2 × 2 table. RESULTS: The ice test has a sensitivity of 0.92 (95% CI 0.62-1.00), specificity of 0.79 (95% CI 0.56-1.00), PPV of 0.73 (95% CI 0.48-0.90), and NPV of 0.94 (95% CI 0.70-1.00). CONCLUSIONS: Due to its high negative predictive value the ice test is still a reliable and useful bed-side test.

Ultrasound-guided steroid injection to treat mild ulnar neuropathy at the elbow.

There exists no "gold standard" in the treatment of ulnar neuropathy at the elbow (UNE). We treated 7 patients with mild UNE using a local steroid injection with ultrasonographic monitoring. At clinical follow-up after 6 weeks, 4 patients had improved, 2 were stable, and 1 reported an increase in symptoms. Ultrasound-guided steroid injection in mild UNE is safe and could be effective. Further investigation is needed to prove its efficacy.

Persistent genital arousal disorder in 18 Dutch women: Part I. MRI, EEG, and transvaginal ultrasonography investigations.

INTRODUCTION: Systematic blood analysis and electroencephalographic (EEG) and magnetic resonance imaging (MRI) study in women with persistent genital arousal disorder (PGAD) are needed to get more insight into the syndrome's etiology and pathogenesis. AIM: To investigate possible causes of PGAD. METHODS: Eighteen women fulfilling all five criteria of PGAD were included in the study. In-depth interviews and routine blood and hormonal investigations, together with EEG and MRI scans of the brain and pelvis, were performed in all women. Transvaginal ultrasonography (TVUS) and MRI scans with contrast were performed in subjects who had indications of abnormalities on MRI scans. MAIN OUTCOME MEASURES: Detailed descriptions of blood, neurophysiological, and (neuro)anatomical findings. RESULTS: The majority of women experienced PGAD symptoms during early menopause without existing laboratory abnormalities, besides those belonging to menopause. The EEG studies showed no severe diffuse or focal abnormalities. The MRI scans of the brain did not show any specific abnormalities, apart from an already known pericallosal aneurysm in one patient and postoperative findings of meningioma surgery in another patient. MRI scans of the pelvis showed clear to moderate-clear indications of pelvic varices in 55% of the women. TVUS confirmed the existence of pelvic varices in nine women; these had a mild, moderate, and severe extent in two, three, and four women. In three of the latter four patients, an additional MRI with gadolinium contrast disclosed mild to moderate dilation of ovarian veins; 39% of the women were known with varices of one or both legs. CONCLUSIONS: The current study did not show overt pathology that could causally explain PGAD sensations. As pelvic varices are a common finding in adult women, the current findings do not allow the conclusion that PGAD is causally related to pelvic varices. However, the high prevalence of pelvic and lower limb varices in the current group of women warrants further research of their role in PGAD.

Safety and effectiveness of selective carotid angioplasty prior to cardiac surgery: a single-centre matched case-control study.

OBJECTIVES: Reducing the rate of postoperative stroke after cardiac surgery remains challenging, especially in patients with occlusive cerebrovascular disease. Angioplasty in all patients with high-grade carotid artery stenosis has not been shown to be effective in reducing the post-surgical stroke rate. In this study, we present the initial results of a different approach using selective carotid angioplasty only in patients with poor intracranial collaterals. METHODS: We conducted a single-centre study to assess the safety of this procedure. The postangioplasty complication rate of the study group was compared to that of patients who were scheduled for symptomatic carotid artery angioplasty. To determine the effectiveness of this procedure, the post-cardiac surgery complication rate of the study group was compared with that of the matched case controls. RESULTS: Twenty-two patients were treated with selective carotid angioplasty without developing persistent major neurological complications. All patients except 1 patient subsequently underwent surgery without developing persistent major neurological disabilities. Two patients died of cardiogenic shock within 30 days. CONCLUSIONS: Selective carotid angioplasty prior to cardiac surgery in patients with a presumed high risk of stroke was relatively safe and effective in this study group. Although this strategy does not prevent stroke in these high-risk patients, data suggest that this approach shifts the postoperative type of stroke from a severe haemodynamic stroke towards a minor embolic stroke with favourable neurological outcomes. Larger studies are needed to determine whether this strategy can effectively eliminate the occurrence of haemodynamic stroke after cardiac surgery.

Impact of the Haga Braincare Strategy on the burden of haemodynamic and embolic strokes related to cardiac surgery.

OBJECTIVES: This study prospectively evaluates the impact of the Haga Braincare Strategy (HBS) on the occurrence of haemodynamic and embolic stroke in a cohort of patients who underwent coronay artery bypass grafting (CABG), valve replacement of a combination of both types of surgery between 2012 and 2015 at the Haga Teaching Hospitals. METHODS: The HBS is a dual strategy based on a preoperative vascular work-up of the cerebral circulation by transcranial Doppler and a perioperative monitoring of the cerebral circulation by cerebral oximetry. Duplex of the carotid arteries and/or computed tomography angiography prior to surgery was performed in high-risk patients. Patients with severe carotid artery stenosis were scheduled for carotid angioplasty prior to surgery or waived from surgery. RESULTS: A total of 1065 patients were included. Poor cerebral haemodynamics were identified by transcranial Doppler in 2.1% of patients (n = 22). Based on the HBS, 3 patients were waived from surgery, 4 received preoperative carotid angioplasty followed by cardiac surgery and the remaining patients were operated while being monitored with bilateral cerebral oximetry sensors. In all, 2.2% of the study group experienced a stroke (n = 23), of which none were classified as haemodynamic. Most of the remaining presumed embolic strokes showed a minor to moderate stroke severity. CONCLUSIONS: In this single-centre prospective follow-up study, surveillance of cerebral perfusion by the HBS eliminated the occurrence of haemodynamic stroke while most of the residual strokes had a good to favourable prognosis.

Continuous quantitative EEG monitoring in hemispheric stroke patients using the brain symmetry index.

BACKGROUND AND PURPOSE: There is increased awareness that continuous brain monitoring might benefit neurological patients, because it may allow detection of derangement of brain function in a possible reversible state, allowing early intervention. Here, we explore if quantitative continuous electroencephalography (cEEG) monitoring is technically feasible and possibly clinically relevant in patients with acute ischemic hemispheric stroke.Materials- Twenty-one consecutive patients with an acute hemispheric stroke were monitored in our stroke unit, using cEEG for 12 to 24 hours on the day of admission. EEGs were quantified using a particular measure for symmetry, the brain symmetry index (BSI). This measure was subsequently correlated with the clinical condition of the patient using the National Institute of Health Stroke Scale (NIHSS). RESULTS: cEEG was technically feasible. We found a most satisfying positive correlation between the BSI and the NIHSS, with rho approximately 0.86 (P<0.01). CONCLUSIONS: Technically, cEEG monitoring posed no major problems. It was found that the BSI correlates satisfactorily with the clinical neurological condition of our stroke patients. This suggests that the BSI can be used as a measure to monitor possible changes of brain function in this patient category.

A brain symmetry index (BSI) for online EEG monitoring in carotid endarterectomy.

INTRODUCTION: Carotid endarterectomy is a common procedure as a secondary prevention of stroke, and one of the early controversies in carotid surgery is centered around whether a shunt should be used during this procedure. Although various EEG parameters have been proposed to determine if the brain is at risk during carotid artery clamping, the common procedure is still the visual assessment of the EEG. We propose a brain symmetry index (BSI), that has been implemented as an on-line quantitative EEG parameter, as an additional criterion for shunt need in carotid endarterectomy. METHODS: The BSI captures a particular asymmetry in spectral power between the two cerebral hemispheres, and is normalized between 0 (perfect symmetry) and 1 (maximal asymmetry). The index was evaluated retrospectively in a group of 57 operations in which the EEG and the transcranial Doppler were used as criteria for shunt insertion. In addition, after online implementation of the algorithm, several patients have been evaluated prospectively. RESULTS: If no visual EEG changes were detected, it was found that the change in BSI from baseline, DeltaBSIor=0.06. In this group, one patient suffered from intraoperative stroke and one patient died, most likely from a hyperperfusion syndrome. CONCLUSIONS: The BSI may assist in the visual EEG analysis during carotid endarterectomy and provides a quantitative measure for electroencephalographic asymmetry due to cerebral hypo-perfusion. In patients with a change in the BSI (DeltaBSI) smaller than 0.03 during test clamping, visual EEG analysis showed no changes, whereas if visual EEG analysis did warrant shunting, it was found that DeltaBSI>or=0.06.

Diagnostic value of history, physical examination and needle electromyography in diagnosing lumbosacral radiculopathy.

To examine the diagnostic value of history, physical examination and needle EMG in predicting nerve root compression on MRI in patients with clinical suspicion of lumbosacral radicular syndrome (LSRS). Subjects comprised 202 consecutive patients from January 2006 to March 2007 with suspicion of LSRS referred by general practitioners. Clinical evaluation consisted of history, physical examination, EMG and MRI. Bivariate and multiple logistic regression analyses were used to calculate the diagnostic value of each test item compared to radiological nerve root compression. 95 patients (47%) had radiological nerve root compression. Significant predictors of radiological nerve root compression were dermatomal radiation [odds ratio (OR) 2.1], more pain on coughing, sneezing or straining (OR 2.4), positive straight leg raising (OR 3.0) and ongoing denervation on EMG (OR 4.5). 15 patients (7%) had ongoing denervation on EMG without radiological nerve root compression. In clinical practice, dermatomal radiation, more pain on coughing, sneezing or straining, positive straight leg raising and ongoing denervation on EMG may be used to predict nerve root compression on MRI. EMG may also be of additional value in patient with clinical suspicion of lumbosacral radicular syndrome without nerve root involvement on MRI.

Botulinum toxin type A in simple motor tics: short-term and long-term treatment-effects.

To determine the short-term and long-term treatment-effects of botulinum toxin type A in simple motor tics, we analyzed 15 consecutive patients (18 tics) with simple motor tics that were treated every 3 months with injections of BTX-A. Efficacy (rated on a 4-level scale) and duration of effect of the first 2 and last 2 (if treated 5 times or more) treatments were recorded, as well as latency of response, changes of premonitory urges (PMUs) and possible side effects. Total number of treatments for each tic varied from 2 to 50 (mean 11, median 6). In 16 of 18 tics (89%) short-term efficacy was reported successful (good or moderate). Long-term efficacy was reported in 12 tics of which 11 showed similar or even increased beneficial effects. Premonitory urge (PMU) was reported in 8 patients (53%). PMU, if present, lessened or disappeared after treatment with BTX-A. A permanent remission of the treated tic was seen in 3 patients with a maximum follow-up of 10 years. BTX-A appears a safe and effective treatment for simple motor tics and retains its efficacy after long-term treatment. BTX may also induce permanent remission of the treated tics and effects of BTX are not restricted to merely motor behaviour.

Vestibulotoxicity as a consequence of systemically administered tobramycin in cystic fibrosis patients.

CONCLUSION: The reported prevalence of vestibulotoxicity (30.4%) in cystic fibrosis (CF) patients supports vestibulotoxicity screening in CF patients during or after tobramycin exposure. Prospective longitudinal investigation is required for a more specific evidence-based proposal. OBJECTIVE: To investigate the prevalence of tobramycin-induced vestibulotoxicity in CF patients, as it had not been investigated before. PATIENTS AND METHODS: In this observational cohort study, 23 CF patient volunteers from the Haga Teaching Hospital Adult CF centre who had been exposed to at least one treatment with systemically administered tobramycin were included. Subjective feelings of dizziness were measured using validated questionnaires and vestibular symptoms were assessed by physical examination. Electronystagmography (ENG) with caloric irrigation was used as the gold standard. RESULTS: Peripheral vestibular loss was found in seven patients (7/23 = 30.4%). Central vestibular loss was found in one patient. Analysis of the 19 completed questionnaires showed that 12 patients (12/19 = 63.2%) did not experience dizziness and 3 patients (3/19 = 15/8%) experienced specific vestibular symptoms. The results of the questionnaire could not predict the results of ENG with caloric irrigation. Physical examination showed no abnormalities in any patients. No age- or dose-related predictive factors were found.

Comparative prospective trial of 3 intramedullary plugs in cemented total hip arthroplasty.

We assessed the occlusion and stability of 3 intramedullary plugs used to restrict the femoral canal before primary cemented arthroplasty. In a prospective, randomized trial the Biosem (SEM, Montrouge, France), Cemlock (Sulzer Orthopaedic Ltd, Baar, Switzerland), and Thackray (DePuy International Ltd, Leeds, England) plug were compared in 93 hip joints replaced by the Stanmore hip prosthesis. We considered a range of 1 cm on the postoperative radiograph a measuring fault. According to the definition, 43% (40/93) were not stable. The percentages of deficient plugs were: Biosem 78% (25/32), Cemlock 32% (9/28), and Thackray 18% (6/33). The differences found between the Biosem and Cemlock and between the Biosem and Thackray were significant. No significant effect was seen regarding the sizes of the plugs used. Comparison of the smaller sizes of the prosthesis versus the larger sizes showed a significant effect on the stability of the plugs.