Use of magnetic source imaging to assess recovery after severe traumatic brain injury-an MEG pilot study.

Rationale: Severe TBI (sTBI) is a devastating neurological injury that comprises a significant global trauma burden. Early comprehensive neurocritical care and rehabilitation improve outcomes for such patients, although better diagnostic and prognostic tools are necessary to guide personalized treatment plans. Methods: In this study, we explored the feasibility of conducting resting state magnetoencephalography (MEG) in a case series of sTBI patients acutely after injury (~7 days), and then about 1.5 and 8 months after injury. Synthetic aperture magnetometry (SAM) was utilized to localize source power in the canonical frequency bands of delta, theta, alpha, beta, and gamma, as well as DC-80 Hz. Results: At the first scan, SAM source maps revealed zones of hypofunction, islands of preserved activity, and hemispheric asymmetry across bandwidths, with markedly reduced power on the side of injury for each patient. GCS scores improved at scan 2 and by scan 3 the patients were ambulatory. The SAM maps for scans 2 and 3 varied, with most patients showing increasing power over time, especially in gamma, but a continued reduction in power in damaged areas and hemispheric asymmetry and/or relative diminishment in power at the site of injury. At the group level for scan 1, there was a large excess of neural generators operating within the delta band relative to control participants, while the number of neural generators for beta and gamma were significantly reduced. At scan 2 there was increased beta power relative to controls. At scan 3 there was increased group-wise delta power in comparison to controls. Conclusion: In summary, this pilot study shows that MEG can be safely used to monitor and track the recovery of brain function in patients with severe TBI as well as to identify patient-specific regions of decreased or altered brain function. Such MEG maps of brain function may be used in the future to tailor patient-specific rehabilitation plans to target regions of altered spectral power with neurostimulation and other treatments.

Anti-N-methyl-D-aspartate receptor encephalitis in pregnancy associated with teratoma.

A 36-year-old pregnant woman with a prior history of depression and recent gunshot wounds presented with sudden deterioration in her mental status. Clinical examination revealed psychosis, hallucinations, and lack of orientation, with an otherwise normal neurological and cardiorespiratory examination. Computed tomographic scan of her head was normal, and she was diagnosed with acute psychosis and excited delirium. She did not respond to supraphysiologic dosages of antipsychotic therapy and needed physical restraints for combativeness and agitation. Her cerebrospinal fluid analysis was negative for an infectious etiology, but was positive for anti-N-methyl-D-aspartate receptor encephalitis antibodies. Abdominal imaging revealed a right-sided ovarian cyst. Subsequently she underwent right-sided oophorectomy. Postoperatively the patient continued to have intermittent episodes of agitation requiring antipsychotic medications. Later, she was safely transitioned to home care with family support.

Intermittent fasting with ketogenic diet: A combination approach for management of chronic diseases.

Intermittent Fasting (IF) is the consumption of food and drinks within a defined time, while the ketogenic diet (KD) switches the metabolism from glucose to fats. Continuation of intermittent fasting leads to the generation of ketones, the exact mechanism for a ketogenic diet. This article discusses the types of IF and KD, the monitoring required, and the mechanisms underlying IF and KD, followed by disorders in which the combination strategy could be applied. The strategies for successfully applying combination therapy are included, along with recommendations for the primary care physicians (PCP) which could serve as a handy guide for patient management. This opinion article could serve as the baseline for future clinical studies since there is an utmost need for developing new wholesome strategies for managing chronic disorders.

Diet-microbiome-gut-brain nexus in acute and chronic brain injury.

In recent years, appreciation for the gut microbiome and its relationship to human health has emerged as a facilitator of maintaining healthy physiology and a contributor to numerous human diseases. The contribution of the microbiome in modulating the gut-brain axis has gained significant attention in recent years, extensively studied in chronic brain injuries such as Epilepsy and Alzheimer's Disease. Furthermore, there is growing evidence that gut microbiome also contributes to acute brain injuries like stroke(s) and traumatic brain injury. Microbiome-gut-brain communications are bidirectional and involve metabolite production and modulation of immune and neuronal functions. The microbiome plays two distinct roles: it beneficially modulates immune system and neuronal functions; however, abnormalities in the host's microbiome also exacerbates neuronal damage or delays the recovery from acute injuries. After brain injury, several inflammatory changes, such as the necrosis and apoptosis of neuronal tissue, propagates downward inflammatory signals to disrupt the microbiome homeostasis; however, microbiome dysbiosis impacts the upward signaling to the brain and interferes with recovery in neuronal functions and brain health. Diet is a superlative modulator of microbiome and is known to impact the gut-brain axis, including its influence on acute and neuronal injuries. In this review, we discussed the differential microbiome changes in both acute and chronic brain injuries, as well as the therapeutic importance of modulation by diets and probiotics. We emphasize the mechanistic studies based on animal models and their translational or clinical relationship by reviewing human studies.

Pure Thalamic Infarct: 8-Year Follow-Up Study in a Hospital in China.

Pure thalamic infarct is a rare lacunar stroke type, with little known about long-term outcomes. This 8-year, single-center, retrospective study evaluated the clinical background, etiology, Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification, and 8-year follow-up results in 27 patients with pure thalamic infarcts identified by MR diffusion-weighted imaging in Dalian, China. All patients presented chief complaints of limb weakness or sensory disturbances. Hypertension (24/27, 88.9%), diabetes (12/27, 44.4%), atrial fibrillation (1/27, 3.7%), hyperlipidemia (10/27, 37%), hyperhomocysteinemia (6/27, 22.2%), smoking history (10/27, 37%; 9/15, 60% for men; 1/12, 8.3% for women), and excessive alcohol consumption history (7/27, 25.9%; 7/15, 46.7% for men; 0 for women) were observed in our patient population. Based on TOAST classification, 1 patient had large artery atherosclerosis (7.14%), 23 had small vessel occlusion (SVO; 85.2%), and 3 patients were unidentified due to lack of cerebral angiography. The thalamic blood supply classification were as follows: 23 (85.2%), inferolateral territory; 1 (3.7%), tuberothalamic territory; 2 (7.4%), combination of tuberothalamic and paramedian arteries; 1 (3.7%), combination of inferolateral and paramedian arteries; 0, posterior choroidal arteries. During the 8-year follow-up, 3 patients died of colon cancer, multi-organ failure, and kidney failure, respectively; 7 presented with a recurrent stroke; while 10 recovered well with their risk factors under control. In conclusion, our cohort of pure thalamic infarcts were mainly due to SVO (TOAST), with hypertension as the main risk factor, and the inferolateral artery as the most implicated arterial territory. Less severe outcome or stroke recurrence are identified in long-term follow-up of pure thalamic infarcts. Other comorbidities would be cause of death in aged patients.

Reversible cerebral vasoconstriction syndrome (RCVS) caused by over-the-counter calcium supplement ingestion.

A 59-year-old woman was found unresponsive at home. Initial neurologic examination revealed aphasia and right-sided weakness. Laboratory results demonstrated a serum calcium level of 17.3 mg/dL (corrected serum calcium for albumin concentration was 16.8 mg/dL). Extensive workup for intrinsic aetiology of hypercalcemia was unrevealing. Further discussion with family members and investigation of the patient's home for over-the-counter medications and herbal supplements revealed chronic ingestion of calcium carbonate tablets. CT angiogram of the brain revealed multifocal intracranial vascular segmental narrowing, which resolved on a follow-up cerebral angiogram done 2 days later. These findings were consistent with reversible cerebral vasoconstriction syndrome.Appropriate blood pressure control with parenteral agents, calcium channel blockade with nimodipine and supportive care therapies resulted in significant improvement in neurologic status. By discharge, patient had near-complete resolution of neurologic symptoms.

Ipsilateral Ptosis and Contralateral Ataxic Hemiparesis as Initial Symptoms of Combined Tuberothalamic and Paramedian Artery Infarction.

Thalamic infarcts, accounting for approximately 14% of lacunar infarcts, exhibit varied clinical manifestations due to complex anatomy of nuclei and varying blood supply. Pure and combined types of thalamic infarctions have been summarized in some paper, but information of cerebral angiography was not mentioned. Here we report a rare case of combined tuberothalamic and paramedian artery occlusion presenting with ipsilateral ptosis and contralateral ataxic hemiparesis.