Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. MATERIALS AND METHODS: From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017-2019). RESULTS: Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0-106.0), pre-COVID-19; 40.0 min (27.0-98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0-560.0), pre-COVID-19; 184.0 min (134.0-271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID19, 46.7% in pre-COVID-19, p=0.039). CONCLUSION: During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.

Ventriculoperitoneal Shunt without Hair Shaving Using Absorbable Suture Materials.

OBJECTIVE: Infection is one of most devastating complications in ventriculoperitoneal (VP) shunt surgery. Preoperative hair removal has traditionally been performed to reduce infectious complications. We performed VP shunt surgeries and evaluated the prevalence of infection in patients who were shaved and those who were unshaven. METHODS: A retrospective analysis was conducted of 82 patients with hydrocephalus of various pathologies who underwent VP shunt surgery, with or without having the head shaved, between March 2010 and March 2017. For patients in the non-shaved group (n=36), absorbable suture materials were used for wound closure, and Nylon sutures or staples were used in the shaved group (n=46). We evaluated the infection outcomes of patients in the two groups. RESULTS: There was no difference in the average age of patients in the two groups. In the non-shaved group, there were no infections, while two patients in the shaved group required revision because of shunt infection. CONCLUSION: Non-shaved shunt surgery may be safe and effective, with no increase of infection rate. We recommend that shunt procedures could be performed without shaving the hair, which may increase patients' satisfaction without increasing infection risk.

Comparison of the Affective Responses to Continuous Training and High-Intensity Interval Training Protocols: Application of the Dual-Mode Model.

ABSTRACT: Alicea, SK, Parrott, AD, Manos, TM, and Kwon, YS. Comparison of the affective responses to continuous training and high-intensity interval training protocols: application of the dual-mode model. J Strength Cond Res 35(11): 3069-3075, 2021-High-intensity interval training (HIIT) is time-efficient and has physiological benefits similar to or greater than that of continuous training (CT); however, there are mixed results regarding how HIIT protocols influence affect. The purpose of this study was to compare acute affective responses between HIIT and CT protocols over time using the Dual-Mode Model (DMM) as a theoretical framework. Subjects included 12 healthy women (aged 19-28 years) who completed a HIIT protocol consisting of a 2-minute work interval (100% V̇o2max) followed by a 2-minute rest interval (∼55% V̇o2max), and a CT protocol set at the workrate corresponding to their respiratory compensation point (RCP; ∼80% V̇o2max). Protocols were matched for average intensity, total duration, and energy expenditure. After blood pressure, anthropometrics, body composition, and V̇o2max measurements were taken, responses were recorded for affect (Feeling Scale [FS]), arousal (Felt Arousal Scale [FAS]), and rate of perceived exertion (RPE) before each protocol, during the last 10 seconds of every 2 minutes during the protocol, and at time points 2, 5, and 10 minutes after the protocol. Heart rate was also monitored continuously, and exercise enjoyment was measured before and after exercise. A repeated-measures analysis of variance revealed no significant differences in affect between CT (M = 2.5, SD = 2.1) and HIIT (M = 2.6, SD = 2.1) protocols over the duration of the exercise. There were no significant differences in mean RPE between CT (M = 12.9, SD = 2.7) and HIIT (M = 13.0, SD = 1.9) protocols (t = 0.333, p = 0.745) or in enjoyment between CT (M = 2.3, SD = 1.1) and HIIT (M = 2.0, SD = 0.9) protocols (t = -0.288, p = 0.492). In addition, based on visual inspection, the general patterning of the mean FS and FAS values between HIIT and CT was similar within the circumplex model, supporting the DMM. In conclusion, a HIIT protocol at V̇o2max and 1:1 exercise:rest interval did not result in a different affect response, perceived exertion, or enjoyment level when compared with a CT protocol at RCP.

Effect of Rest Interval Duration on the Volume Completed During a High-Intensity Bench Press Exercise.

ABSTRACT: Hernandez, DJ, Healy, S, Giacomini, ML, and Kwon, YS. Effect of rest interval duration on the volume completed during a high-intensity bench press exercise. J Strength Cond Res 35(11): 2981-2987, 2021-Between-set rest intervals (RIs) are one of the most important variables in resistance training; however, no known research has investigated the effects of RIs greater than 5 minutes during high-intensity strength training. The purpose of this research was to examine the effects of 3 different RIs on repetition sustainability and training volume (sets × reps × resistance) during a high-intensity bench press exercise. Fifteen resistance-trained male subjects (mean ± SD, age = 25.5 ± 4.5 years, and bench press 1 repetition maximum [1RM] ratio [1RM/body mass] = 1.39 ± 0.1) completed 3 experimental sessions, during which 4 sets of the bench press were performed with 85% of 1RM load. Subjects performed the bench press using 3 different RIs in a random counterbalanced design. Data were analyzed using both a one- and two-way analysis of variance with repeated measures. As sets progressed, repetitions were significantly different (p < 0.05) between all RIs, and only the 8-minute RI (p < 0.05) allowed for the complete sustainability of repetitions over 4 consecutive sets. Subjects attained the greatest training volume (p < 0.05) using an 8-minute RI between sets compared with a 2- or 5-minute RI. Similarly, a significantly greater training volume was achieved using the 5-minute RI compared with the 2-minute RI. Resistance-trained men, with the goal of greater volume during strength training, would benefit from longer RIs, specifically using an 8-minute RI between 4 consecutive sets of a bench press exercise.

STA-Distal ACA Bypass Using a Contralateral STA Interposition Graft for Symptomatic ACA Stenosis.

Intracranial arterial stenosis usually occurs due to atherosclerosis and is considered the most common cause of stroke worldwide. Although the effectiveness of bypass surgery for ischemic stroke is controversial, the superficial temporal artery to the middle cerebral artery bypass for ischemic stroke is a common procedure. In our report, a 50-year-old man presented with sudden-onset left side weakness and dysarthria. An angiogram showed significant stenosis in the junction of the right cavernous-supraclinoid internal carotid artery and right pericallosal artery. Symptoms altered between improvement and deterioration. Magnetic resonance imaging showed a repeated progression of anterior cerebral artery (ACA) infarction despite maximal medical therapy. We performed a STA-ACA bypass with contralateral STA interposition. Postoperative course was uneventful with no further progression of symptoms. Thus, bypass surgery may be considered in patients with symptomatic stenosis or occlusion of the ACA, especially when patients present progressive symptoms despite maximal medical therapy.

Dual microcatheter coil embolization of acutely ruptured wide-necked intracranial aneurysms.

The dual microcatheter technique is an alternative treatment for stent-assisted coiling in acutely ruptured wide-necked aneurysms because of no antiplatelet therapy. We assessed the safety and efficacy of this technique in ruptured wide-necked aneurysms. Between March 2008 and March 2016, 56 acutely ruptured aneurysms were treated with the dual microcatheter technique. The angiographic results, treatment-related complications, and clinical outcome were documented. Angiographic follow-up was available in 37 patients at a mean of 20.6 months (6 to 81 months). On the postembolization angiograms, 27 (48.2%) aneurysms showed complete occlusion (Raymond 1), 15 (26.8%) showed neck remnant (Raymond 2), and 14 (25.0%) showed body remnant (Raymond 3). Treatment-related complications occurred in seven patients (12.5%) and six patients remained asymptomatic. The permanent complication rate was 1.8% (1/56). A good outcome (modified Rankin Scale (mRS) score, 0-2) was observed in 64.3% of patients at the time of discharge. Five patients had died, all of the sequelae of subarachnoid hemorrhage. The overall mortality rate was 8.9% (5/56); however, the treatment-related mortality rate was 0%. Of the 37 aneurysms for which angiographic follow-up was available, 21 (56.8%) aneurysms demonstrated recanalization. Five aneurysms with recanalization were retreated endovascularly. There was one aneurysm re-rupture on follow-up and it rebled 21 months after the initial procedure. The dual microcatheter technique is a safe and effective treatment for acutely ruptured wide-necked aneurysms due to low treatment-related complication and mortality rate. However, the high rate of postembolization incomplete occlusion and recanalization remains as the main challenge.

Multiloculated Hydrocephalus: Open Craniotomy or Endoscopy?

Multiloculated hydrocephalus (MLH) is a condition in which patients have multiple, separate abnormal cerebrospinal fluid collections with no communication between them. Despite technical advancements in pediatric neurosurgery, neurological outcomes are poor in these patients and the approach to this pathology remains problematic especially given individual anatomic complexity and cerebrospinal fluid (CSF) hydrodynamics. A uniform surgical strategy has not yet been developed. Current treatment options for MLH are microsurgical fenestration of separate compartments by open craniotomy or endoscopy, shunt surgery in which multiple catheters are placed in the compartments, and combinations of these modalities. Craniotomy for fenestration allows better visualization of the compartments and membranes, and it can offer easy fenestration or excision of membranes and wide communication of cystic compartments. Hemostasis is more easily achieved. However, because of profound loss of CSF during surgery, open craniotomy is associated with an increased chance of subdural hygroma and/or hematoma collection and shunt malfunction. Endoscopy has advantages such as minimal invasiveness, avoidance of brain retraction, less blood loss, faster operation time, and shorter hospital stay. Disadvantages are also similar to those of open craniotomy. Intraoperative bleeding can usually be easily managed by irrigation or coagulation. However, handling of significant intraoperative bleeding is not as easy. Currently, endoscopic fenestration tends to be performed more often as initial treatment and open craniotomy may be useful in patients requiring repeated endoscopic procedures.

Craniotomy or Decompressive Craniectomy for Acute Subdural Hematomas: Surgical Selection and Clinical Outcome.

OBJECTIVE: Craniotomy (CO) and decompressive craniectomy (DC) are two main surgical options for acute subdural hematomas (ASDH). However, optimal selection of surgical modality is unclear and decision may vary with surgeon's experience. To clarify this point, we analyzed preoperative findings and surgical outcome of patients with ASDH treated with CO or DC. METHODS: From January 2010 to December 2014, data for 46 patients with ASDH who underwent CO or DC were retrospectively reviewed. The demographic, clinical, imaging and clinical outcomes were analyzed and statistically compared. RESULTS: Twenty (43%) patients underwent CO and 26 (57%) patients received DC. In DC group, preoperative Glascow Coma Scale was lower (p=0.034), and more patient had non-reactive pupil (p=0.004). Computed tomography findings of DC group showed more frequent subarachnoid hemorrhage (p=0.003). Six month modified Rankin Scale showed favorable outcome in 60% of CO group and 23% of DC group (p=0.004). DC was done in patient with more unfavorable preoperative features (p=0.017). Patients with few unfavorable preoperative features (<6) had good outcome with CO (p<0.001). CONCLUSION: In selective cases of few unfavorable clinical findings, CO may also be an effective surgical option for ASDH. Although DC remains to be standard of surgical modality for patients with poor clinical status, CO can be an alternative considering the possible complications of DC.

Early Experience of Automated Intraventricular Type Intracranial Pressure Monitoring (LiquoGuard®) for Severe Traumatic Brain Injury Patients.

OBJECTIVE: The LiquoGuard® system is a new ventricular-type monitoring device that facilitates intracranial pressure (ICP)-controlled or volume-controlled drainage of cerebrospinal fluid (CSF). The purpose of this study is to report the authors' experience with the LiquoGuard® ICP monitoring system, as well as the clinical safety, usefulness, and limitations of this device in the management of patients with traumatic brain injury (TBI). METHODS: Intraventricular ICP monitoring was performed on 10 patients with TBI using the LiquoGuard® monitoring system. ICP measurements, volume of drained CSF, and clinical outcomes were analyzed and discussed. RESULTS: ICP monitoring was performed on 10 patients for a mean duration of 6.9 days. With a mean 82,718 records per patient, the mean initial ICP was 16.4 mm Hg and the average ICP across the total duration of monitoring was 15.5 mm Hg. The mean volume of drained CSF was 29.2 cc/day, with no CSF drained in 4 patients. Seven of 10 patients showed 1 or 2 episodes of abnormal ICP measurements. No patient exhibited complications associated with ICP monitoring. CONCLUSION: The LiquoGuard® system is a versatile tool in the management of TBI patients. Its use is both reliable and feasible for ICP monitoring and therapeutic drainage of CSF. However, episodes of abnormal ICP measurements were frequently observed in patients with slit ventricles, and further study may be needed to overcome this issue.

Venous angioarchitectural features of intracranial dural arteriovenous shunt and its relation to the clinical course.

INTRODUCTION: The aim of this study is to assess the relationship between the venous angioarchitectural features and the clinical course of intracranial dural arteriovenous shunt (DAVS) with cortical venous reflux (CVR). METHODS: With institutional review board approval, 41 patients (M:F = 24:17; median age, 52 years (range, 1-72 years), median follow-up; 1.5 years; partial treatment, n = 36) with persistent CVR were included. We evaluated the initial presentation and the incidence of annual morbidity (hemorrhage or new/worsened nonhemorrhagic neurological deficit (NHND)) according to the venous angiographic patterns-isolated venous sinus, occlusion of the draining sinus, direct pial venous drainage, pseudophlebitic pattern, venous ectasia, brisk venous drainage, and length of pial vein reflux-on digital subtraction angiography. Cox regression was performed to identify independent factors for clinical course. RESULTS: During 111.9 patient-years of follow-up, the overall annual morbidity rate was 11.6 % (mortality; n = 3, rate; 2.6 %/year). Hemorrhage occurred in five patients (12.2 %, rate; 4.5 %/year) and new/worsened NHND occurred in eight patients (19.5 %, rate; 7.2 %/year). Patients with isolated venous sinus, direct pial venous drainage, and pseudophlebitic pattern were associated with initial aggressive presentation. Venous ectasia was associated with initial hemorrhagic presentation. Brisk venous drainage was associated with initial benign presentation. Patients with isolated venous sinus showed a poor clinical course with a higher annual incidence of hemorrhage or new/worsened NHND (91.2 %/year vs 9.2 %/year; hazard ratio, 6.681; p = 0.027). CONCLUSIONS: Venous angioarchitectural features may be predictive of the clinical course of DAVSs. DAVS patients with isolated venous sinus may be especially at high risk for future aggressive clinical course.

Cavernous malformations associated with dural arteriovenous shunts in the central nervous system.

INTRODUCTION: Some cerebral cavernous malformations (CCMs) may be associated with vascular malformations that occur on the capillary-venous side of the cerebral circulation. The association between CCMs and dural arteriovenous shunts (DAVSs) is not well known. The purpose of this study is to investigate the relationship between CCMs and DAVSs. METHODS: We retrospectively analyzed 179 patients diagnosed as intracranial DAVSs and performed with digital subtraction angiography (DSA). The DSA images were investigated for the location, cortical venous reflux (CVR), multiplicity, and treatment method/result of DAVS. MR images were investigated for the location, number, and size of CCMs and correlated with the DSA images. RESULTS: Six of the 179 patients with DAVSs presented with coexistent CCMs (3.4 %; M/F = 3:3; mean age, 38 ± 22 years). Five of the six DAVS patients with CCMs were associated with CVR (83 %). The total number of CCMs associated with DAVS was 20. Multiple CCMs (range, 2-7) were seen in four (66 %) of six patients. Eighteen (90 %) of the 20 CCMs were located on the ipsilateral hemisphere of the CVR (n = 10) or adjacent to the deep venous reflux (n = 8). Five de novo CCMs were detected in two patients. All de novo CCMs were located on the ipsilateral hemisphere of the DAVS with CVR or juxtapositioned to abnormally dilated deep vein. CONCLUSION: CCMs may develop in association to DAVSs. The relationship between CCMs and DAVSs suggests the venous pathogenic origin of CCMs and the role of venous hypertension in the de novo development of CCMs.

Spontaneous symptomatic intracranial vertebrobasilar dissection: initial and follow-up imaging findings.

PURPOSE: To evaluate initial radiologic findings of symptomatic intracranial vertebrobasilar dissections (VBDs) as well as the results at follow-up imaging of dissections that are conservatively managed. MATERIALS AND METHODS: The respective institutional review boards approved this retrospective study and waived the need for informed consent. The initial radiologic findings of 210 patients with 230 symptomatic intracranial VBDs were retrospectively evaluated (48 ruptured, 182 unruptured). Those patients had undergone conventional angiography as well as magnetic resonance imaging and/or computed tomographic angiography, so that angiographic shapes and pathognomonic findings (eg, intramural hematoma, intimal flap) could be reviewed. The primary angiographic shapes of the symptomatic intracranial VBDs were subdivided into three groups: (a) dilatation without stenosis, (b) pearl-and-string, and (c) stenosis without dilatation. Furthermore, the radiologic evolution of conservatively managed symptomatic intracranial VBDs was evaluated. The respective frequencies of the radiologic findings at initial and follow-up imaging studies were compared by using χ2 tests. RESULTS: Primary shape differed significantly between ruptured and unruptured symptomatic intracranial VBDs. Most ruptured dissections presented with one of two main structures: dilatation without stenosis or pearl-and-string appearance. The primary shape of unruptured dissections was evenly distributed among the three types of findings. Intramural hematomas were most frequently found in the stenosis-without-dilatation group (42 of 60 [70%]), followed by the pearl-and-string group (27 of 90 [30%]). Intimal flap was most frequently found in the pearl-and-string group (21 of 90 [23%]), followed by the stenosis-without-dilatation group (eight of 60 [13%]). Follow-up results significantly differed by initial VBD shapes: Seventy-four percent (25 of 34) of the dilatation-without-stenosis group showed no change, whereas improvement was observed in 91% (39 of 43) of the stenosis-without-dilatation group (P<.05). Intracranial VBDs with intramural hematoma showed improvement in 63% (34 of 54) of cases, progression occurred in 20% (11 of 54), and only 17% (nine of 54) exhibited no change (P<.05). CONCLUSION: Primary angiographic shapes of symptomatic intracranial VBDs differed between ruptured and unruptured lesions. The stenosis-without-dilatation lesions most frequently exhibited radiologic improvement at follow-up imaging, followed by pearl-and-string and dilatation-without-stenosis lesions.

Comparative clinical results of vertebroplasty using jamshidi® needle and bone void filler for acute vertebral compression fractures.

OBJECTIVE: Percutaneous vertebroplasty (PVP) is an effective treatment modality for management of osteoporotic compression fracture. However physicians sometimes have problems of high pressure in cement delivery and cement leakage when using Jamshidi® needle (JN). Bone void filler (BVF) has larger lumen which may possibly diminish these problems. This study aims to compare the radiologic and clinical outcome of JN and BVF for PVP. METHODS: One hundred twenty-eight patients were treated with PVP for osteoporotic vertebral compression fracture (VCF) where 46 patients underwent PVP with JN needle and 82 patients with BVF. Radiologic outcome such as kyphotic angle and vertebral body height (VBH) and clinical outcome such as visual analog scale (VAS) scores were measured after treatment in both groups. RESULTS: In JN PVP group, mean of 3.26 cc of polymethylmethacrylate (PMMA) were injected and 4.07 cc in BVF PVP group (p<0.001). For radiologic outcome, no significant difference in kyphotic angle reduction was observed between two groups. Cement leakage developed in 6 patients using JN PVP group and 2 patients using BVF group (p=0.025). No significant difference in improvement of VAS score was observed between JN and BVF PVP groups (p=0.43). CONCLUSION: For the treatment of osteoporotic VCF, usage of BVF for PVP may increase injected volume of cement, easily control the depth and direction of PMMA which may reduce cement leakage. However, improvement of VAS score did not show difference between two groups. Usage of BVF for PVP may be an alternative to JN PVP in selected cases.

Palm cooling delays fatigue during high-intensity bench press exercise.

UNLABELLED: Local cooling can induce an ergogenic effect during a short-term intense exercise. One proposed method of personal cooling involves heat extraction from the palm. PURPOSE: In this study, we hypothesized that local palm cooling (PC) during rest intervals between progressive weight training sets will increase total repetitions and exercise volume in resistance-trained subjects exercising in a thermoneutral (TN) environment. METHODS: Sixteen male subjects (mean +/- SD; age = 26 +/- 6 yr, height = 178 +/- 7 cm, body mass = 81.5 +/- 11.3 kg, one-repetition maximum (1RM) bench press = 123.5 +/- 12.6 kg, weight training experience = 10 +/- 6 yr) performed four sets of 85% 1RM bench press exercise to fatigue, with 3-min rest intervals. Exercise trials were performed in a counterbalanced order for 3 d, separated by at least 3 d: TN, palm heating (PH), and PC. Heating and cooling were applied by placing the hand in a device called the rapid thermal exchanger, set to 45 degrees C for heating or 10 degrees C for cooling. This device heats or cools the palm while negative pressure (-35 to -45 mm Hg) is applied around the hand. RESULTS: Total exercise volume during the four PC sets (2480 +/- 636 kg) was significantly higher than that during TN (1972 +/- 632 kg) and PH sets (2156 +/- 668 kg, P < 0.01). The RMS of the surface EMG with PC exercise was higher (P < 0.01), whereas esophageal temperature (P < 0.05) and RPE (P < 0.05) were lower during PC compared with TN and PH. CONCLUSIONS: PC from 35 degrees C to 20 degrees C temporarily overrides fatigue mechanism(s) during intense intermittent resistance exercise. The mechanisms for this ergogenic function remain unknown.

Palm cooling to reduce heat strain in subjects during simulated armoured vehicle transport.

This study examined whether palm cooling (PC) could reduce heat strain, measured through changes in core, mean skin, mean body temperatures, and thermal sensation in resting hyperthermic subjects wearing chemical protective garments. Ten male subjects performed three exercise bouts (6.1 km h(-1), 2-4% grade) in a hot, dry environment [mean (SD) air temperature 42.2 (0.5 degrees C), relative humidity 36.5 (1%)] until core temperature reached 38.8 degrees C. Subjects then simulated transport in an armoured vehicle by resting in a seated position for 50 min with either no cooling (NC), (PC at 10 degrees C) or palm cooling with vacuum application around the hand (PCVAC, 10 degrees C, 7.47 kPa negative pressure). Core, skin, and mean body temperatures with PC and PCVAC were lower (P < 0.05) than NC from 15 to 50 min of cooling, and thermal sensation was lower (P < 0.05) from 30 to 50 min, with no differences in any variables between PC and PCVAC. Maximal heat extraction averaged 42 (12 W), and core temperature was reduced by 0.38 (0.21 degrees C) after 50 min of PC. Heat extraction with PC was modest compared to other cooling approaches in the literature.