Persistent hemiplegia with normal intraoperative neurophysiological monitoring in supratentorial neurosurgery: a case report and review of literature.

Intraoperative neurophysiological monitoring (IONM) is needed for evaluating and demonstrating the integrity of the central and peripheral nervous system during surgical manoeuvres that take place in proximity to eloquent motor and somatosensory nervous structures. The integrity of the monitored motor pathways is not always followed by consistent clinical normality, particularly in the first hours/days following surgery, when surgical resection involves brain structures such as the supplementary motor areas (SMA). We report the case of a patient who underwent surgical excision of a right frontal glioblastoma with normal preoperative, intraoperative (IONM), and postoperative central motor conduction, but with persistent postoperative hemiplegia (> 6 months). The literature regarding SMA syndrome and its diagnosis and prognosis is reviewed.

Ultrasound-guided-electromyography in plegic muscle: Usefulness of nerve stimulation.

INTRODUCTION/AIMS: In traumatic nerve lesions (TNLs), motor unit potentials (MUPs) may be difficult to detect in early injury. Ultrasound-guided electromyography (US-EMG) can aid in identifying areas of muscle activation, but its sensitivity can be improved. In this study we compare the sensitivity of US-EMG alone with US-EMG after peripheral nerve stimulation (NC-US-EMG) to better identify active muscle regions. METHODS: In this prospective study, 32 patients with severe TNLs were evaluated with standard EMG (ST-EMG), US-EMG, and NC-US-EMG at baseline (T0), after 2 to 3 months (T1), and after 5 to 6 months (T2). RESULTS: NC-US-EMG was more sensitive in detecting MUPs compared with US-EMG and ST-EMG at T0 (19 patients vs 14 and 5 patients, respectively). In addition, both US-guided techniques were more sensitive than ST-EMG in detecting MUPs (ST-EMG vs US-EMG: P = .014; ST-EMG vs NC-US-EMG: P = .003). At T1, ST-EMG remained less sensitive NC-US-EMG (P = .019). No significant differences were observed among the three techniques at T2. DISCUSSION: In the evaluation of severe TNLs, the combination of peripheral nerve stimulation and US increases the sensitivity of EMG for MUP detection at baseline and 2 to 3 months postinjury.

Hand Measurement System Based on Haptic and Vision Devices towards Post-Stroke Patients.

Diagnostics of a hand requires measurements of kinematics and joint limits. The standard tools for this purpose are manual devices such as goniometers which allow measuring only one joint simultaneously, making the diagnostics time-consuming. The paper presents a system for automatic measurement and computer presentation of essential parameters of a hand. Constructed software uses an integrated vision system, a haptic device for measurement, and has a web-based user interface. The system provides a simplified way to obtain hand parameters, such as hand size, wrist, and finger range of motions, using the homogeneous-matrix-based notation. The haptic device allows for active measurement of the wrist's range of motion and additional force measurement. A study was conducted to determine the accuracy and repeatability of measurements compared to the gold standard. The system functionality was confirmed on five healthy participants, with results showing comparable results to manual measurements regarding fingers' lengths. The study showed that the finger's basic kinematic structure could be measured by a vision system with a mean difference to caliper measurement of 4.5 mm and repeatability with the Standard Deviations up to 0.7 mm. Joint angle limits measurement achieved poorer results with a mean difference to goniometer of 23.6º. Force measurements taken by the haptic device showed the repeatability with a Standard Deviation of 0.7 N. The presented system allows for a unified measurement and a collection of important parameters of a human hand with therapist interface visualization and control with potential use for post-stroke patients' precise rehabilitation.

Sensing System for Plegic or Paretic Hands Self-Training Motivation.

Patients after stroke with paretic or plegic hands require frequent exercises to promote neuroplasticity and to improve hand joint mobilization. Available devices for hand exercising are intended for persons with some level of hand control or provide continuous passive motion with limited patient involvement. Patients can benefit from self-exercising where they use the other hand to exercise the plegic or paretic one. However, post-stroke neuropsychological complications, apathy, and cognitive impairments such as forgetfulness make regular self-exercising difficult. This paper describes Przypominajka v2-a system intended to support self-exercising, remind about it, and motivate patients. We propose a glove-based device with an on-device machine-learning-based exercise scoring, a tablet-based interface, and a web-based application for therapists. The feasibility of on-device inference and the accuracy of correct exercise classification was evaluated on four healthy participants. Whole system use was described in a case study with a patient with a paretic hand. The anomaly classification has an accuracy of 91.3% and f1 value of 91.6% but achieves poorer results for new users (78% and 81%). The case study showed that patients had a positive reaction to exercising with Przypominajka, but there were issues relating to sensor glove: ease of putting on and clarity of instructions. The paper presents a new way in which sensor systems can support the rehabilitation of after-stroke patients with an on-device machine-learning-based classification that can accurately score and contribute to patient motivation.

Unexpected immediate postoperative resolution of long-standing neurological deficits following extracranial-intracranial bypass: a report of three cases.

While intracranial ischemic insults often result in neuronal death and permanent neurological deficits, some patients may develop potentially reversible neurological dysfunction from persistent hypoperfusion, as surviving neurons remain in an "idling" state. We report a unique series of three patients with long-standing neurological deficits who underwent EC-IC bypass for repeated TIAs and demonstrated unexpected, rapid resolution of long-standing pre-existing neurological deficits. We suggest that these individuals harbored regions of underperfused, idling neurons that responded rapidly to restored cerebral reperfusion.

Effect of Combination of Non-Invasive Spinal Cord Electrical Stimulation and Serotonin Receptor Activation in Patients with Chronic Spinal Cord Lesion.

We analyzed the efficiency of percutaneous electrical stimulation of the spinal cord and serotonin receptor activation in rehabilitation of paralyzed patients. Four-week course of spinal cord electrical stimulation combined with mechanotherapy produced positive shifts in the status of chronically paralyzed patients. Serotonin receptor activation potentiated the effect of spinal cord stimulation and can be regarded as an additional neurorehabilitation option.

Clinical Occurrences in the Neurorehabilitation of Dogs with Severe Spinal Cord Injury.

This prospective observational clinical study in a population of tetraplegic and paraplegic dogs (n = 488) with or without deep pain sensation, similar to humans ASIA A and B, investigated the prevalence of clinical occurrences in a rehabilitation center with a hospitalization regime between 15 days and 9 months. A checklist of occurrences was used for easy identification and monitoring, resulting in a total of 79.5% occurrences. There were 58% of dogs with neurogenic bladder, 35.5% with diarrhea, 21.3% with urinary incontinence, and 20.5% with fecal incontinence. A low incidence of respiratory problems (e.g., pneumonia) and urinary tract infections may suggest the efficacy of some applied measures in this study, such as thoracic and abdominal POCUS evaluation, positioning strategies, physical exercises, respiratory kinesiotherapy, and early implementation of a functional neurorehabilitation protocol. These can be essential measures to prevent clinical occurrences, mainly in breeds such as the French Bulldog and the Dachshund.

Usefulness of D-dimer and Ultrasonography Screening for Detecting Deep Vein Thrombosis in Patients with Spinal Cord Injury Undergoing Rehabilitation.

Patients with spinal cord injury (SCI) are at an increased risk of deep vein thrombosis (DVT). This study aims at assessing usefulness of D-dimer and compressive Doppler ultrasonography (CDUS) for detecting DVT in patients undergoing rehabilitation at various time-points post-SCI. One-hundred forty-five patients were divided into three groups based on time elapsed since SCI: I (≥3 weeks to 3 months), II (≥3 to 6 months), and III (≥6 months). On admission, D-dimer plasma level measurement and CDUS of the lower limbs venous system were performed. DVT was diagnosed using CDUS in 15 patients (10.3% of entire group), more frequently in group I (22.2% of group) and II (11.7%) compared to group III (1.5%). Most DVT patients received thromboprophylaxis (80%) and were asymptomatic or mildly symptomatic (60%). Median D-dimer was elevated in patients with DVT from all groups, and also patients without DVT from groups I and II, but not group III. D-dimers were higher in patients with DVT than without DVT in the entire group (p = 0.001) and group I (p = 0.02), but not in groups II and III. The risk of DVT in SCI patients undergoing rehabilitation and thromboprophylaxis including asymptomatic or mildly symptomatic cases, is high within 6 months post-injury, and especially within 3 months. Measurement of D-dimer level should be complemented by routine CDUS for detecting DVT within 6 months post-SCI. Over 6 months, the usefulness of D-dimer screening alone is better for DVT detection.

Ultrasound guidance increases diagnostic yield of needle EMG in plegic muscle.

OBJECTIVES: To increase the specificity of motor unit potential (MUPs) detection by using ultrasound guided electromyography (USG-EMG) in patients with muscle plegia due to traumatic nerve lesions. METHODS: Forty-six patients with recent nerve trauma underwent baseline standard EMG (ST-EMG) evaluation with evidence of absent MUPs. In 41 of them, ST-EMG was repeated after 2-3 months (T1) and the patients were accordingly divided in two groups: ST-EMG+ (if MUPs were detected) or ST-EMG- (MUPs not detected). Then, ST-EMG- patients underwent muscle ultrasound evaluation (M-US) and, if isles of muscular contractility were found, they also had USG-EMG. The same protocol was repeated 4-6 months after baseline (T2). RESULTS: At T1, 22/41 patients were ST-EMG+. While 19/41 were ST-EMG-; 9 of these patients had M-US consistent with residual muscular activity, for that reasons underwent USG-EMG with 7 of 9 demonstrating MUPs (at T2 all of these 7 patients resulted ST-EMG). In the other 2 patients, we found no MUPs at T1 but they became ST-EMG+ or USG-EMG positive at T2. The remaining 10 ST-EMG- patients had no EMG or US evidence of muscle contraction at T1, but at T2 2 of 10 became ST-EMG+ and 2 had USG-EMG showing MUPs. In the remaining 6 patients still M-US negative at T2, complete denervation was diagnosed. Concerning the 22 patients who were ST-EMG+ at T1, all but one showed increase of MUPs at T2. CONCLUSIONS: In this study, we demonstrated the utility of US guidance when performing EMG evaluation in locating isles of muscular contractility in patients who have no detectable MUPs on EMG after nerve trauma. SIGNIFICANCE: USG-EMG significantly increases the specificity of needle EMG allowing earlier detection of MUPs.

Fibrocartilaginous Embolism of the Spinal Cord in Children: A Case Report and Review of Literature.

Fibrocartilaginous embolism is assumed to be caused by fibrocartilaginous nucleus pulposus component migration through retrograde embolization to the spinal cord artery. Fibrocartilaginous embolism is currently not well recognized among pediatricians because of its rarity. We describe a previously healthy 15-year-old soccer player who, after kicking a ball, developed progressive weakness in both legs and urinary retention the next day. Magnetic resonance imaging revealed T2 hyperintensity in the anterior horn of the spinal cord at the Th12/L1 level with Schmorl node at the level of L1/2. We also review the previous literature on fibrocartilaginous embolism of the spinal cord in children (less than18 years age); a total of 25 pediatric patients, including our patient, were identified. The median age was 14 years, and 64% of the reviewed patients were female. The most common trigger event was intense exercise or sports. The neurological symptoms started within one day in most cases, and the time to symptom peak varied from a few hours to two weeks. The most common initial neurological symptoms were weakness or plegia (100%), followed by paresthesia or numbness (48%). Affected areas of the spinal cord were distributed evenly from the cervical to thoracolumbar regions. Although steroids and anticoagulants were most commonly used, the prognosis was quite poor (mild to severe sequelae with three deaths). Although fibrocartilaginous embolism is a very rare condition, physicians should be aware of the characteristics and include fibrocartilaginous embolism of the spinal cord in their differential diagnosis, especially for physically active patients.