Anterolateral papillary muscle suction causing low flow in a COVID-19 patient without medical history: a case report of central extracorporeal life support with left ventricular apex decompression.

BACKGROUND: Left ventricular (LV) decompression is an essential strategy for improving early survival in patients with refractory cardiogenic shock. Low pump flow in patients on extracorporeal life support (ECLS) with LV apex decompression is a life-threatening issue. However, identifying the underlying causes of low flow can be challenging. CASE PRESENTATION: A 38-year-old woman with COVID-19-related fulminant myocarditis was treated with central ECLS with LV apex decompression. The pump flow in the intensive care unit (ICU) was intermittently low, and low flow alerts were frequent. The initial evaluation based on pressure monitor waveforms and transthoracic echocardiography failed to identify the underlying cause. Prompt bedside transesophageal echocardiography (TEE) revealed that the anterolateral papillary muscle was suctioned into the vent cannula of the LV apex during systole. The patient underwent a repeat sternal midline incision in the operating room, and the cannula at the LV apex was repositioned. There were no further suction events after the repositioning, and the patient was weaned from ECLS 12 days after admission to the ICU. The patient was discharged in a stable condition and without neurological deficits. CONCLUSIONS: TEE is an important diagnostic tool to identify the underlying cause of low flow flow in patients undergoing ECLS with LV apex decompression.

Vessel wall imaging and carotid artery stenting for recurrent cervical internal carotid artery vasospasm syndrome: illustrative case.

BACKGROUND: Recurrent cervical internal carotid artery vasospasm syndrome (RCICVS) causes cerebral infarction, ocular symptoms, and occasionally chest pain accompanied by coronary artery vasospasm. The etiology and optimal treatment remain unclear. OBSERVATIONS: The authors report a patient with drug-resistant RCICVS who underwent carotid artery stenting (CAS). Magnetic resonance angiography revealed recurrent vasospasm in the cervical segment of the internal carotid artery (ICA). Vessel wall imaging during an ischemic attack revealed vascular wall thickening of the ICA, similar to that in reversible cerebral vasoconstriction syndrome. The superior cervical ganglion was identified at the anteromedial side of the stenosis site. Coronary artery stenosis was also detected. After CAS, the symptoms of cerebral ischemia were prevented for 2 years, but bilateral ocular and chest symptoms did occur. LESSONS: Vessel wall imaging findings suggest that RCICVS is a sympathetic nervous system-related disease. CAS could be an effective treatment for drug-resistant RCICVS to prevent cerebral ischemic events.

Subanesthetic-dose propofol infusion for preventing emergence agitation in children: a retrospective observational study.

PURPOSE: Anesthesia maintenance using propofol and a propofol bolus dose at the end of surgery have been shown to prevent emergence agitation (EA). However, the preventive effect of subanesthetic propofol infusion during sevoflurane anesthesia on EA remains unknown. We aimed to evaluate the effect of subanesthetic propofol infusion on EA in children. METHODS: We retrospectively compared the incidences of severe EA requiring pharmacological intervention in children who underwent adenoidectomy, tonsillectomy with or without adenoidectomy, or strabismus surgery between maintenance with sevoflurane alone (sevoflurane group) and maintenance with subanesthetic propofol with sevoflurane (combination group). A multivariable logistic regression model adjusted for confounders was used to assess the association between anesthesia methods and the occurrence of EA. Additionally, we estimated the direct effect of anesthesia methods by a mediation analysis, excluding the indirect effects of intraoperative fentanyl and droperidol administration. RESULTS: Among 244 eligible patients, 132 and 112 were in the sevoflurane and combination groups, respectively. The crude incidence of EA was significantly lower in the combination group (17.0% [n = 19]) than in the sevoflurane group (33.3% [n = 44]) (P = 0.005). After adjusting for confounders, the incidence of EA was still significantly lower in the combination group (adjusted odds ratio [aOR]: 0.48, 95% confidence interval [CI] 0.25-0.91). The mediation analysis revealed a direct association of anesthesia methods with a lower EA incidence in the combination group (aOR: 0.48, 95% CI 0.24-0.93) than in the sevoflurane group. CONCLUSION: Subanesthetic propofol infusion may effectively prevent severe EA requiring the administration of opioids or sedatives.

Case report: Backward gait training combined with gait-synchronized cerebellar transcranial alternating current stimulation in progressive supranuclear palsy.

Progressive supranuclear palsy (PSP) is characterized by recurrent falls caused by postural instability, and a backward gait is considered beneficial for postural instability. Furthermore, a recent approach for rehabilitation combined with gait-oriented synchronized stimulation using non-invasive transcranial patterned stimulation could be promising for balance function. Here, we present a case of PSP with backward gait training combined with gait-synchronized transcranial alternating current stimulation (tACS). A 70-year-old woman with PSP-Richardson's syndrome underwent backward gait training combined with synchronized cerebellar tACS. Initially, she underwent short-term intervention with combined training of backward gait with synchronized cerebellar tACS, asynchronized, or sham stimulation according to the N-of-1 study design. Synchronized tACS training demonstrated a decrease in postural instability, whereas asynchronized or sham stimulation did not. The additional long-term interventions of combined backward gait training with synchronized cerebellar tACS demonstrated further decrease in postural instability with improvements in gait speed, balance function, and fall-related self-efficacy in daily life. The present case describes a novel approach for motor symptoms in a patient with PSP. Backward gait training with synchronized cerebellar tACS may be a promising therapeutic approach.

Case report: A novel approach of closed-loop brain stimulation combined with robot gait training in post-stroke gait disturbance.

Most post-stroke patients have long-lasting gait disturbances that reduce their daily activities. They often show impaired hip and knee joint flexion and ankle dorsiflexion of the lower limbs during the swing phase of gait, which is controlled by the corticospinal tract from the primary motor cortex (M1). Recently, we reported that gait-synchronized closed-loop brain stimulation targeting swing phase-related activity in the affected M1 can improve gait function in post-stroke patients. Subsequently, a gait-training robot (Orthobot®) was developed that could assist lower-limb joint movements during the swing phase of gait. Therefore, we investigated whether gait-synchronized closed-loop brain stimulation combined with robot-assisted training targeting the swing phase could enhance the recovery of post-stroke gait disturbance. A 57-year-old female patient with chronic post-stroke hemiparesis underwent closed-loop brain stimulation combined with robot-assisted training for 10 min 2 years after left pons infarction. For closed-loop brain stimulation, we used transcranial oscillatory electrical current stimulation over the lesioned M1 foot area with 1.5 mA of DC offset and 0-3 mA of sine-wave formed currents triggered by the paretic heel contact to set the maximum current just before the swing phase (intervention A; two times repeated, A1 and A2). According to the N-of-1 study design, we also performed sham stimulation (intervention B) and control stimulation not targeting the swing phase (intervention C) combined with robot-assisted training in the order of A1-B-A2-C interventions. As a result, we found larger improvements in gait speed, the Timed Up and Go test result, and muscle strength after the A1 and A2 interventions than after the B and C interventions. After confirming the short-term effects, we performed an additional long-term intervention twice a week for 5 weeks, for a total of 10 sessions. Gait parameters also largely improved after long-term intervention. Gait-synchronized closed-loop brain stimulation combined with robot-assisted training targeting the swing phase of gait may promote the recovery of gait function in post-stroke patients. Further studies with a larger number of patients are necessary.

Vascular occlusion in a previously unaffected territory after treatment with intravenous plasminogen activator: illustrative case.

BACKGROUND: Intravenous tissue plasminogen activator (IV t-PA) is effective for the treatment of distal artery occlusion. However, after the use of IV t-PA, vascular occlusion in unaffected territories may occur. Early recurrent ischemic stroke (ERIS) is defined as the occurrence of new neurological symptoms that suggest the involvement of initially unaffected vascular territories after intravenous thrombolysis (IVT). The authors reviewed the cases of ERIS that occurred within 24 hours after treatment with IVT. OBSERVATIONS: A 75-year-old woman with occlusion in the M2 segment of the left middle cerebral artery (MCA) was treated with IV t-PA. However, 360 minutes later, the patient presented with occlusion in the M1 distal segment of the contralateral side, the right MCA, which was recanalized by endovascular treatment. Her modified Rankin Scale score was 4; however, aphasia was not observed. She was transferred to a rehabilitation hospital after 3 months. LESSONS: ERIS is an extremely rare but catastrophic event. The underlying mechanism of ERIS most likely involves the disintegration and subsequent scattering of a preexisting intracardiac thrombus. Hence, caution must be used when managing not only hemorrhagic complications but also ischemic complications after IV t-PA. Endovascular management may be the only effective treatment for this type of large vessel occlusion.