Is preoperative fat infiltration in lumbar spine muscles associated with worse clinical outcomes after lumbar interbody fusion?

PURPOSE: Lumbar musculature has a fundamental role in spine stability and spinal balance. Muscle atrophy and fat infiltration play an important role in pain pathophysiology. Accordingly, the preoperative condition of lumbar muscles may influence clinical outcomes after surgical treatment. In this context, the aim of this study was to evaluate the association between preoperative lumbar paravertebral muscle fat infiltration and clinical outcomes after lumbar interbody fusion. METHODS: A retrospective study of patients with lumbar pathology submitted to lumbar transforaminal (TLIF) or posterior interbody fusion (PLIF) was performed, with a minimum of two years of follow-up. Preoperative lumbar magnetic resonance imaging (MRI) images were classified for fat infiltration in lumbar multifidus muscle and correlated with clinical outcomes. RESULTS: Seventy-five patients were included: 24 submitted to PLIF and 51 to TLIF. Most patients underwent surgery for spondylolisthesis (67%). Higher degrees of fat infiltration were associated with more advanced age (54.8 vs. 49.1 years old, p = 0.04) and more leg pain after surgery (p = 0.04). No statistically significant differences in other clinical outcomes such as Oswestry Disability Index, visual analogue scale for back and leg pain, self-reported back pain relief, return to work and overall satisfaction were found between different groups of fat infiltration. The improvement in leg pain was associated with improvement in self-reported lumbar pain (p < 0.001). CONCLUSION: Age and preoperative degree of fat infiltration may be important to predict improvement in leg pain after lumbar interbody fusion. The absence of solid literature on this topic and universal assessment methodologies reinforce the need for further studies.

Nationwide Access to Endovascular Treatment for Acute Ischemic Stroke in Portugal.

INTRODUCTION: Since the publication of endovascular treatment trials and European Stroke Guidelines, Portugal has re-organized stroke healthcare. The nine centers performing endovascular treatment are not equally distributed within the country, which may lead to differential access to endovascular treatment. Our main aim was to perform a descriptive analysis of the main treatment metrics regarding endovascular treatment in mainland Portugal and its administrative districts. MATERIAL AND METHODS: A retrospective national multicentric cohort study was conducted, including all ischemic stroke patients treated with endovascular treatment in mainland Portugal over two years (July 2015 to June 2017). All endovascular treatment centers contributed to an anonymized database. Demographic, stroke-related and procedure-related variables were collected. Crude endovascular treatment rates were calculated per 100 000 inhabitants for mainland Portugal, and each district and endovascular treatment standardized ratios (indirect age-sex standardization) were also calculated. Patient time metrics were computed as the median time between stroke onset, first-door, and puncture. RESULTS: A total of 1625 endovascular treatment procedures were registered. The endovascular treatment rate was 8.27/100 000 inhabitants/year. We found regional heterogeneity in endovascular treatment rates (1.58 to 16.53/100 000/year), with higher rates in districts closer to endovascular treatment centers. When analyzed by district, the median time from stroke onset to puncture ranged from 212 to 432 minutes, reflecting regional heterogeneity. DISCUSSION: Overall endovascular treatment rates and procedural times in Portugal are comparable to other international registries. We found geographic heterogeneity, with lower endovascular treatment rates and longer onset-to-puncture time in southern and inner regions. CONCLUSION: The overall national rate of EVT in the first two years after the organization of EVT-capable centers is one of the highest among European countries, however, significant regional disparities were documented. Moreover, stroke-onset-to-first-door times and in-hospital procedural times in the EVT centers were comparable to those reported in the randomized controlled trials performed in high-volume tertiary hospitals.

Introdução: A aprovação do tratamento endovascular para o acidente vascular cerebral isquémico obrigou à reorganização dos cuidados de saúde em Portugal. Os nove centros que realizam tratamento endovascular não estão distribuídos equitativamente pelo território, o que poderá causar acesso diferencial a tratamento. O principal objetivo deste estudo é realizar uma análise descritiva da frequência e métricas temporais do tratamento endovascular em Portugal continental e seus distritos. Material e Métodos: Estudo de coorte nacional multicêntrico, incluindo todos os doentes com acidente vascular cerebral isquémico submetidos a tratamento endovascular em Portugal continental durante um período de dois anos (julho 2015 a junho 2017). Foram colhidos dados demográficos, relacionados com o acidente vascular cerebral e variáveis do procedimento. Taxas de tratamento endovascular brutas e ajustadas (ajuste indireto a idade e sexo) foram calculadas por 100 000 habitantes/ano para Portugal continental e cada distrito. Métricas de procedimento como tempo entre instalação, primeira porta e punção foram também analisadas. Resultados: Foram registados 1625 tratamentos endovasculares, indicando uma taxa bruta nacional de tratamento endovascular de 8,27/100 000 habitantes/ano. As taxas de tratamento endovascular entre distritos variaram entre 1,58 e 16,53/100 000/ano, com taxas mais elevadas nos distritos próximos a hospitais com tratamento endovascular. O tempo entre sintomas e punção femural entre distritos variou entre 212 e 432 minutos. Discussão: A análise nacional a taxas de tratamento endovascular e tempos de atuação é comparável a outros registos internacionais. Verificaram-se heterogeneidades geográficas, com taxas de tratamento endovascular menores e maior tempo para tratamento nos distritos do sul e interior. Conclusão: Portugal continental apresenta uma taxa nacional de tratamento endovascular elevada, apresentando, contudo, assimetrias regionais no acesso. As métricas temporais foram comparáveis com as observadas nos ensaios clínicos piloto.

Red Cell Distribution Width is Associated with 30-day Mortality in Patients with Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Red cell distribution width (RDW) has been associated with mortality and outcome in a wide variety of non-neurological and neurological diseases, namely in myocardial infarction and acute ischemic stroke, and the reason for this is not completely understood. We aimed to investigate RDW as a potential prognostic marker in patients with intracerebral hemorrhage (ICH). METHODS: This is a retrospective study of consecutive patients with acute non-traumatic ICH admitted to a single center during a 4-year period. We reviewed individual clinical records to collect demographic and baseline information, including RDW at admission, 3-month functional status, and incidence of death during follow-up. Baseline computed tomography imaging was reviewed to classify the location of ICH, and to measure ICH volume and perihematomal edema volume. Patients were divided according to quartile distribution of RDW (RDW-Q1-4). RESULTS: The final study population consisted of 358 patients, median age 71 years (interquartile range [IQR] 60-80), 55% were male, and median Glasgow Coma Scale was 14 (IQR 10-15), with a mean follow-up of 17.6 months. Patients with higher RDW values were older (p = 0.003), more frequently presented with an active malignancy (p = 0.005), atrial fibrillation (p < 0.001), intraventricular hemorrhage (p = 0.048), and were anticoagulated (p < 0.001). Three-month functional independence was similar throughout RDW quartiles. RDW-Q4 was independently associated with increased 30-day mortality (adjusted odds ratio = 3.36, 95%CI = 1.48-7.62, p = 0.004), but not independently associated with increased mortality after 30 days (adjusted hazards ratio = 0.71, 95%CI = 0.29-1.73, p = 0.448). CONCLUSIONS: RDW is a robust and independent predictor of 30-day mortality in non-traumatic ICH patients, and further studies to understand this association are warranted.

Contrast-induced neurotoxicity related to neurological endovascular procedures: a systematic review.

Contrast-induced neurotoxicity (CIN) is an adverse reaction to contrast agents which can occur in the context of diagnostic and therapeutic neurological endovascular procedures. Our goal was to conduct a systematic review of patients reported in the literature diagnosed with CIN after neurological endovascular procedures. A systematic search of EMBASE and MEDLINE databases was conducted. Inclusion criteria were age ≥ 18 years; neurological endovascular procedure performed ≤ 24 h before ictus; new manifestations compatible with encephalic dysfunction; imaging performed < 7 days after ictus; exclusion of other causes and manifestations attributed to pre-existing conditions. Forty-eight patients were included, of which 60.4% were female and 60.4% had arterial hypertension; median age was 63 years. The most frequent procedure was diagnostic cerebral angiography (n = 24, 50.0%) and non-ionic contrast agents were more frequently used (n = 40, 83.3%). Twenty-six patients (54.2%) developed clinical manifestations compatible with CIN during or immediately after the procedure, and the most frequent manifestations were encephalopathy, cortical blindness and motor deficit. The most frequent imaging findings were cortical contrast enhancement on CT (n = 23/42), and cortical sulci effacement (n = 18/48). Most patients presented complete clinical recovery (89.6%) at a median time of 3 days. Among patients with neuroimaging changes who underwent follow-up, complete regression of the abnormalities was shown in 81.5% at a median time of 5 days. CIN is a rare adverse reaction in the context of neurological endovascular procedures. Recognition of clinical manifestations and typical imaging abnormalities, while excluding other causes, is essential for diagnosis.

External carotid artery stenting in symptomatic internal carotid artery occlusion.

We report the case of a patient with an anterior ischemic stroke due to tandem occlusion of the left M2 segment and ipsilateral internal carotid artery (ICA), with concomitant severe stenosis of the ipsilateral external carotid artery (ECA) and contralateral ICA, and moderate stenosis of the left vertebral artery (VA); as thrombectomy was not possible, stenting of the right ICA was performed. Two days after significant recovery, the patient showed neurological deterioration when in upright position, and brain magnetic resonance imaging confirmed decreased cerebral blood flow on the left hemisphere. Stenting of the left ECA and balloon angioplasty of the ipsilateral VA were performed in order to increase collateral flow, with an almost complete resolution of symptoms. This case highlights the importance of assessing the collateralization pattern when an ICA occlusion is present, and the potential need to revascularize an ipsilateral stenotic ECA.

Noncontrast computed tomography markers of outcome in intracerebral hemorrhage patients.

Objectives: The characterization of markers capable of predicting clinically significant hematoma growth (HG) in patients with intracerebral hemorrhage (ICH) may be useful for the selection of patients for clinical trials. The use of several noncontrast computed tomography (NCCT) markers has been suggested to stratify the risk of HG. The aim of this study was to analyze HG prediction using different NCCT markers in patients with spontaneous ICH. Methods: Single-hospital retrospective study of patients with spontaneous ICH, who underwent initial NCCT <24 hours after symptom onset. Clinical characteristics were collected and two independent observers analyzed hemorrhage characteristics, volumes and 8 NCCT markers. HG was defined as a growth of ≥33% or ≥6mL in follow-up CT and 30-day survival was collected. Results: 328 patients were included. The most frequent NCCT marker was 'any hypodensity' (68.0%) and the less frequent was the blend sign (11.6%). HG occurred in 22.1% of patients and the only independent predictors for HG were 'any hypodensity' (OR=3.32, 95%CI=1.18-9.34, p=0.023) and the swirl sign (OR=3.98, 95%CI=1.41-11.21, p=0.009). Although all NCCT markers were more frequent in patients who died within 30 days, the only independent predictors were 'irregular margins' (OR=4.54, 95%CI=1.63-12.66, p=0.004) and the satellite sign (OR=2.49, 95%CI=1.07-5.75, p=0.034). NCCT markers with greater sensitivity for HG were 'any hypodensity' and the swirl sign, although with poor positive predictive values and poor areas under the curve. Conclusion: Even though some NCCT markers are independent predictors of HG and 30-day survival, they have suboptimal diagnostic test performances for such outcomes. Abbreviation: OR: odds ratio; 95%CI: 95% confidence interval.

Intracerebral hemorrhage outcome: A comprehensive update.

Non-traumatic intracerebral hemorrhage (ICH) is associated with a significant global burden of disease, and despite being proportionally less frequent than ischemic stroke, in 2010 it was associated with greater worldwide disability-adjusted life years lost. The focus of outcome assessment after ICH has been mortality in most studies, because of the high early case fatality which reaches 40% in some population-based studies. The most robust and consistent predictors of early mortality include age, severity of neurological impairment, hemorrhage volume and antithrombotic therapy at the time of the event. Long-term outcome assessment is multifaceted and includes not only mortality and functional outcome, but also patient self-assessment of the health-related quality of life, occurrence of cognitive impairment, psychiatric disorders, epileptic seizures, recurrent ICH and subsequent thromboembolic events. Several scores which predict mortality and functional outcome after ICH have been validated and are useful in the daily clinical practice, however they must be used in combination with the clinical judgment for individualized patients. Management of patients with ICH both in the acute and chronic phases, requires health care professionals to have a comprehensive and updated perspective on outcome, which informs decisions that are needed to be taken together with the patient and next of kin.

Predictors of hospital readmission 1 year after ischemic stroke.

Predictors of short-term readmission after ischemic stroke have been previously identified, but few studies analyzed predictors of long-term readmission, namely early imaging findings and treatment with intravenous thrombolysis (IVT). To characterize predictors of hospital readmission during the first year after hospitalization for ischemic stroke. The study consists of a retrospective cohort of consecutive ischemic stroke patients admitted in a Portuguese university hospital during 2013, who survived index hospitalization. We collected clinical and imaging information using the electronical clinical record. Information concerning 1-year unplanned hospital readmissions was assessed using the Portuguese electronic Health Data Platform. Descriptive and univariate analyses, Kaplan-Meier survival curve and multivariate survival analysis with Cox regression model were used. We included 480 patients, 50.6 % women, median age 79 years (interquartile range = 68-85). One-year hospital readmissions occurred in 165 patients [34.4 %, 95 % confidence interval (95 % CI) 30.2-38.7]. The main causes for readmission were infectious diseases (43.8 %), ischemic stroke or transient ischemic attack recurrence (13.2 %) and cardiac diseases (6.4 %). In-hospital mortality associated with readmission was 23.0 %. The independent predictors of 1-year hospital readmission after ischemic stroke were admission mini-National Institute of Health Stoke Scale [hazards ratio (HR) 1.05, 95 % CI 1.02-1.08, p = 0.002], and mild or absent early signs of ischemia on admission computed tomography (CT) (HR 0.54, 95 % CI 0.32-0.91, p = 0.021) and IVT (HR 0.11, 95 % CI 0.01-0.80, p = 0.029). Hospital readmission during the first year after ischemic stroke occurs in 1/3 of patients and is associated with high in-hospital mortality. Clinical stroke severity, early signs of ischemia on admission CT, and treatment with IVT are independent predictors of 1-year hospital readmission.

Orolingual angioedema after thrombolysis is not associated with insular cortex ischemia on pre-thrombolysis CT.

OBJECTIVE: Orolingual angioedema (OA) is a well known early complication of treatment with alteplase in ischemic stroke patients. Our aim was to study risk factors for OA in these patients, namely insular cortex ischemia. METHODS: Retrospective case-cohort study using the prospective registry of all consecutive ischemic stroke patients submitted to intravenous thrombolysis with alteplase. Clinical data was retrieved from the registry and medical records. Two independent observers evaluated early signs of insular cortex ischemia on pre-thrombolysis computed tomography (CT) and of insular cortex infarct on early follow-up imaging. Univariate and multivariate analysis were performed to identify predictors of OA. RESULTS: Of the 659 patients with acute ischemic stroke treated with alteplase, 32 developed OA (4.9%, 95%CI=3.3-6.6). Frequency of early signs of insular cortex ischemia on pre-thrombolysis CT and of insular cortex infarct on follow-up imaging was similar in patients with and without OA (p=0.241 and p=0.145, respectively). The only independent predictors of OA occurrence were female sex (OR=5.47, 95%CI=1.98-15.10) and angiotensin-converting enzyme inhibitor (ACE-I) use (OR=3.87, 95%CI=1.71-8.75). CONCLUSIONS: Female sex and ACE-I use are independent risk factors for OA occurrence in ischemic stroke patients treated with alteplase. Early signs of insular cortex ischemia on pre-thrombolysis CT were not significantly associated with OA.

Cerebral gas embolism associated with central venous catheter: Systematic review.

OBJECTIVE: Cerebral gas embolism (CGE) is a potentially catastrophic complication of central venous catheters (CVCs) manipulation or accidental disconnection, which is rarely reported in the literature. This systematic review aims to characterize the clinical manifestations, imaging features and outcome of CGE associated with CVCs. METHODS: Systematic literature search of all published cases of CGE associated with CVCs, and identification of previously unreported local cases. Descriptive analysis of all cases, mortality analysis for cases with individualized data. RESULTS: Of the 158 patients with CGE associated with CVCs found, 71.8% were male and mean age was 56.4years. CGE symptoms frequently occurred while in the upright position. The most frequent neurological manifestation was sudden-onset focal neurological sign (67.7%), followed by coma (59.5%), epileptic seizures (24.7%) and encephalopathy (21.5%). Imaging revealed intracranial air bubbles in 69.1% and cerebral ischemia or edema was demonstrated in 66.7%. Overall mortality was 21.7%, and clinical predictors of mortality were increasing age (p<0.001), coma (p=0.001), cardiorespiratory arrest shortly after symptom onset (p<0.001) and male sex (p=0.035). CONCLUSIONS: CGE associated with CVCs may mimic ischemic stroke, but patients frequently present a severe vigilance disturbance and epileptic seizures. Mortality occurs in 1/5 of patients, which substantiates implementation of protocols and measures to prevent this severe complication of CVC use.

Wake-up Stroke and Stroke within the Therapeutic Window for Thrombolysis Have Similar Clinical Severity, Imaging Characteristics, and Outcome.

BACKGROUND: Wake-up stroke (WUS) represents 25% of all ischemic strokes. There is conflicting evidence concerning clinical severity, imaging characteristics, and outcome when WUS is compared with stroke of known time of onset. Our aim was to compare WUS patients with patients with ischemic stroke within the therapeutic window (STW) for thrombolysis. METHODS: This is a retrospective hospital-based study of all consecutive patients hospitalized for acute ischemic stroke during 2013. Patients with STW, WUS, and WUS with computed tomography (CT) at 3 hours or less after awakening (WUS≤3h) were selected for the study. The methods used include a review of clinical records, an independent quantification of early signs of ischemia on admission CT scan, and determination of functional outcome on follow-up. RESULTS: Of 554 patients evaluated, 190 had STW, 113 had WUS (20.4%), and 25 had WUS≤3h. Among all WUS patients, 33.6% did not have any other formal contraindication for thrombolysis besides undetermined time of onset. WUS patients had demographic characteristics, vascular risk factors, and clinical severity similar to STW patients. Mild or absent early signs of ischemia on admission CT in WUS≤3h patients were similar to those in STW patients when adjusted for clinical severity (odds ratio [OR] = .50, 95% confidence interval [CI]=.17-1.47). Favorable prognosis in WUS≤3h was similar to STW when adjusted for age, clinical severity, and thrombolysis (OR = .53, 95% CI=.09-3.14). CONCLUSIONS: This study strengthens the evidence that clinical and early imaging characteristics of WUS patients are similar to those of patients with stroke who are eligible for thrombolysis based on the time window criteria, and patients with WUS do not have a worse short outcome.

Assessment of three rapid methods for the detection of methicillin-resistant Staphylococcus aureus.

We evaluated three rapid methods to detect methicillin-resistant Staphylococcus aureus (MRSA) and compared them with PCR amplification of mecA. A total of 103 S. aureus strains were studied by MRSA-Screen, BBL Crystal, Velogene Genomic and mecA PCR. All the methods detected the 61 MRSA strains having the mecA gene, showing 100% sensitivity and specificity. Despite the correlation between all the rapid methods and PCR, the ease of use and shorter turnaround time of MRSA-Screen were important factors leading to the selection of this method as the routine screening technique for MRSA.

Evaluación de tres métodos rápidos para la detección de Staphylococcus aureus resistente a la meticilina / Assessment of three rapid methods for the detection of methicillin-resistant Staphylococcus aureus

Se han evaluado tres métodos rápidos para detectar la presencia de Staphylococcus aureus resistente a la meticilina (SARM) y se han comparado con la amplificación del gen mecA mediante reacción en cadena de la polimerasa (PCR). Se estudiaron un total de 103 cepas de S. aureus mediante MRSA-Screen, BBL Crystal, Velogene Genomics y PCR para mecA. Con todos estos métodos se detectaron 61 cepas de SARM que presentaban el gen mecA, con una sensibilidad y especificidad del 100 por ciento.A pesar de la correlación entre todos los métodos rápidos y la PCR, la facilidad de uso y el poco tiempo que lleva a la realización de MRSA-Screen fueron factores importantes para la selección de este método como técnica sistemática de detección de SARM (AU)

Detection of herpesvirus infection of the CNS: the experience of hospital Geral de Santo António.

BACKGROUND: PCR detection of CSF Herpes virus DNA is an important tool in the diagnosis of CNS infections. Use of this test has been shown to have an impact on patient management as measured by shortened patient stays, specific therapeutic intervention, reduction of empirical expensive therapy administration, all of which should translate into significant health care savings. OBJECTIVE: The present study aimed at implementing, and evaluating both clinically and analytically the performance of several commercially available PCR based assays for the detection of Herpes virus infections of the CNS. STUDY DESIGN: A total of 314 patients with suspected CNS Herpesvirus infection were investigated, between 1999 and 2001, by Stair primers PCR. Starting on January 2002, two commercially available real-time-PCR systems were implemented and tested using the Stair primers PCR assay as golden standard and three external control proficiency panels along with serial dilutions of positive clinical samples. RESULTS: Sensitivity of the assay was determined to be <200 copies per ml for HSV and <1250 copies per ml for CMV. Positive results were obtained for 17 patients (6 HSV-1, 1 HSV-2, 1 EBV, 1 CMV, 6 VZV and 2 HHV-6) whose clinical and analytical findings were consistent with the PCR results. A real-time-PCR procedure was introduced in 2002 with similar sensitivity, but a more rapid response. CONCLUSION: Conventional end-point PCR proved useful to the diagnosis of CNS herpes virus infection, with an impact on the clinical intervention. However, the use of Real-Time-PCR has greatly enhanced these advantages, making results available at a much earlier time, thus significantly reducing the need for empirical treatment.

[Three years incidence of dermatophytes in a hospital in Porto (Portugal)]. / Incidência de dermatófitos, durante três anos, num hospital do Porto (Portugal).

We evaluated the incidence of dermatophytes isolated at our hospital in the years of 1997 to 2000 and correlated it with anatomical site and age. Trichophyton rubrum was the predominant species in all anatomical sites, excluding scalp, followed by Microsporum canis, the leading agent of tinea capitis. All dermatophytosis, except tinea capitis by M. canis and Trichophyton schoenleinnii appeared mainly in adult patients. Our results revealed no substantial differences to other portuguese studies regarding the major agents. We found a relatively high incidence of T. schoenleinnii as second tinea capitis agent.