Systemic immune-inflammation index as a predictor of early stroke progression/recurrence in acute atherosclerotic ischemic stroke

OBJECTIVES

Although the systemic immune-inflammatory index (SII) has recently been correlated with stroke severity and functional outcome, the underlying pathogenesis remains largely unknown. The objective of this study was to explore whether SII could predict early neurologic deterioration (END) in different etiologies of acute ischemic stroke.

MATERIALS AND METHODS

From January 2019 to December 2021, a total of 697 consecutive patients with acute ischemic stroke, admitted within 72 hours from stroke onset, were prospectively enrolled. The patients were categorized into 4 groups based on quartiles of SII, calculated as platelets multiplied by neutrophils divided by lymphocytes. END and stroke progression/recurrence were assessed during the first 7 days after stroke onset using predetermined definitions. Logistic regression analysis was conducted to evaluate the association between SII and END, while considering the variation in association across stroke etiologies.

RESULTS

END occurred in 135 patients: 24 (3.4%) for Group I, 25 (3.6%) for Group II, 33 (4.7%) for Group III, and 53 (7.6%) for Group IV. Among the END subtypes, stroke progression/recurrence stroke was the most prevalent. In the logistic regression model, the adjusted odds ratios (ORs) of END and stroke progression/recurrence for group IV were 2.51 (95% CI, 1.27-4.95) and 1.98 (95% CI, 1.03-3.89), respectively. Among the stroke etiologies, group IV showed a significant increase in END (OR 4.24; 95% CI, 1.42-12.64) and stroke progression/recurrence (OR 4.13; 95% CI, 1.39-12.27) specifically in case of large artery atherosclerosis.

CONCLUSIONS

SII independently predicts early stroke progression/recurrence in patients with acute atherosclerotic ischemic stroke.

The simplification of the insomnia severity index and epworth sleepiness scale using machine learning models

Insomnia and excessive daytime sleepiness (EDS) are the most common complaints in sleep clinics, and the cost of healthcare services associated with them have also increased significantly. Though the brief questionnaires such as the Insomnia Severity Index (ISI) and Epworth Sleepiness Scale (ESS) can be useful to assess insomnia and EDS, there are some limitations to apply for large numbers of patients. As the researches using the Internet of Things technology become more common, the need for the simplification of sleep questionnaires has been also growing. We aimed to simplify ISI and ESS using machine learning algorithms and deep neural networks with attention models. The medical records of 1,241 patients who examined polysomnography for insomnia or EDS were analyzed. All patients are classified into five groups according to the severity of insomnia and EDS. To develop the model, six machine learning algorithms were firstly applied. After going through normalization, the process with the CNN+ Attention model was applied. We classified a group with an accuracy of 93% even with only the results of 6 items (ISI1a, ISI1b, ISI3, ISI5, ESS4, ESS7). We simplified the sleep questionnaires with maintaining high accuracy by using machine learning models.

Advances in Intraoperative Neurophysiology During Microvascular Decompression Surgery for Hemifacial Spasm

Microvascular decompression (MVD) is a widely used surgical intervention to relieve the abnormal compression of a facial nerve caused by an artery or vein that results in hemifacial spasm (HFS). Various intraoperative neurophysiologic monitoring (ION) and mapping methodologies have been used since the 1980s, including brainstem auditory evoked potentials, lateral-spread responses, Z-L responses, facial corticobulbar motor evoked potentials, and blink reflexes. These methods have been applied to detect neuronal damage, to optimize the successful decompression of a facial nerve, to predict clinical outcomes, and to identify changes in the excitability of a facial nerve and its nucleus during MVD. This has resulted in multiple studies continuously investigating the clinical application of ION during MVD in patients with HFS. In this study we aimed to review the specific advances in methodologies and clinical research related to ION techniques used in MVD surgery for HFS over the last decade. These advances have enabled clinicians to improve the efficacy and surgical outcomes of MVD, and they provide deeper insight into the pathophysiology of the disease.

A prewarning sign for hearing loss by brainstem auditory evoked potentials during microvascular decompression surgery for hemifacial spasm

OBJECTIVE

We aimed to define the prewarning sign of brainstem auditory evoked potentials (BAEPs) associated with cerebellar retraction (CR) during microvascular decompression surgery for hemifacial spasm.

METHODS

A total of 241 patients with a latency prolongation of 1 ms or an amplitude decrement of 50% of wave V were analyzed. According to BAEPs before significant changes during CR, patients were classified into Groups A (latency prolongation of wave I [≥0.5 ms] without prolongation of the I-III interpeak interval [<0.5 ms]) and B (no latency prolongation of wave I [<0.5 ms] with prolongation of the I-III interpeak interval [≥0.5 ms]). BAEPs and postoperative hearing loss (HL) were compared between the two groups.

RESULTS

Group B comprised 160 (66.4%) patients. With maximal changes in wave V, latency prolongation (≥1 ms) with amplitude decrement (≥50%) was more common in Group B (p < 0.018). At the end of the operation, wave V loss was observed in 11 patients, including 10 patients from Group B. Five patients developed postoperative HL; all were from Group B.

CONCLUSIONS

Latency prolongation of wave III during CR was associated with serious BAEPs changes and postoperative HL.

SIGNIFICANCE

Latency prolongation of wave III is a significant prewarning sign.

Recent glycemic control can predict the progressive motor deficits of acute subcortical infarction with diabetes or prediabetes

BACKGROUND AND PURPOSE

The predictors of progressive motor deficits in acute subcortical infarctions are still controversial. It is not known whether glycemic control influences on stroke progression.

METHODS

A total of 268 consecutive patients with diabetes or prediabetes who had acute (< 24 h) subcortical infarction were enrolled. (1) All patients were divided into 4 groups by quartile of glycated hemoglobin (HbA1c). (2) Only the patients with diabetes were divided by effective glycemic control. Progressive motor deficits were prospectively captured and defined as an increase of motor score ≥ 1 on the upper or lower limb items of the National Institute of Health Stroke Scale within 72 h from stroke onset.

RESULTS

Progressive motor deficits occur in 8/78 (10.3%) for ≤ 5.9, 15/61 (24.6%) for 6.0-6.4, 16/62 (25.8%) for 6.5-7.4, and 30/67 (44.8%) for ≥ 7.5. In diabetic patients alone, those occur in 5/37 (13.5%) for ≤ 6.5, 10/42 (23.8%) for 6.6-7.0, 12/42 (28.6%) for 7.1-8.0, and 24/50 (48.0%) for ≥ 8.1. An adjusted OR of progressive motor deficits was 2.61 (95% confidence interval [CI] 0.98-7.00, P = .056) for 6.0-6.4, 3.42 (95% CI 1.27-9.18, P = .015) for 6.5-7.4, and 6.65 (95% CI 2.38-18.62, P < .001) for ≥ 7.5. In diabetic patients alone, those were 3.15 (95% CI 0.89-11.15, P = .075) for 6.6-7.0, 2.90 (95% CI 0.79-10.61, P = .107) for 7.1-8.0, and 4.17 (95% CI 1.07-16.25, P = .038) for ≥ 8.1. The optimal cutoff value of HbA1c was 6.65% in discriminating progressive motor deficits.

CONCLUSION

Increased HbA1c was associated with higher incidence of progressive motor deficits in acute subcortical infarction with diabetes and prediabetes.

Dizziness in patients with early stages of Parkinson's disease: Prevalence, clinical characteristics and implications

AIM

The clinical features and implications of dizziness in patients with Parkinson's disease (PD) remain little known. This study aimed to investigate the clinical characteristics of dizziness, and the association of dizziness with motor and non-motor symptoms in early stages of PD.

METHODS

Demographics and clinical characteristics of patients with early PD (disease duration ≤5 years) were retrospectively assessed. The characteristics of dizziness were surveyed in each parkinsonian patient according to existence, frequency, duration and nature. Not only motor symptoms, but also non-motor scales for global cognition, anxiety, depression and fatigue were evaluated to identify risk factors of dizziness.

RESULTS

Of a total of 80 patients with early PD, 37 (46.3%) had dizziness. The characteristics of dizziness included short duration (seconds to minutes) and frequent occurrence (several times in a day or a week). The most common type of dizziness was orthostatic (40.5%), followed by non-specific and disequilibrium type. Among many scales for motor and non-motor symptoms, dizzy patients with early PD showed lower scores of Montreal Cognitive representing global cognition than non-dizzy people. A lower Montreal Cognitive Assessment score was the only factor significantly related to dizziness in patients with early PD.

CONCLUSIONS

We found that dizziness frequently occurs in early parkinsonian patients. It is highly linked to low Montreal Cognitive Assessment scores in patients with early PD, inferring that dizziness might be a potential non-motor symptom associated with cognitive decline in PD. Geriatr Gerontol Int 2020; 20: 443-447.

Intraoperative Neurophysiological Monitoring during Microvascular Decompression Surgery for Hemifacial Spasm

Hemifacial spasm (HFS) is due to the vascular compression of the facial nerve at its root exit zone (REZ). Microvascular decompression (MVD) of the facial nerve near the REZ is an effective treatment for HFS. In MVD for HFS, intraoperative neurophysiological monitoring (INM) has two purposes. The first purpose is to prevent injury to neural structures such as the vestibulocochlear nerve and facial nerve during MVD surgery, which is possible through INM of brainstem auditory evoked potential and facial nerve electromyography (EMG). The second purpose is the unique feature of MVD for HFS, which is to assess and optimize the effectiveness of the vascular decompression. The purpose is achieved mainly through monitoring of abnormal facial nerve EMG that is called as lateral spread response (LSR) and is also partially possible through Z-L response, facial F-wave, and facial motor evoked potentials. Based on the information regarding INM mentioned above, MVD for HFS can be considered as a more safe and effective treatment.

Vascular Complications in Microvascular Decompression: A Survey of 4000 Operations

BACKGROUND

Vascular complications in posterior fossa surgery, even in microvascular decompression (MVD) involving a small cranial opening, can have catastrophic consequences. We analyzed these complications to determine the incidence, risk factors, prognosis, and preventive measures involved.

METHODS

Between April 1997 and March 2018, 4000 consecutive patients with neurovascular compression syndrome were admitted and underwent MVD. We reviewed the medical records of patients who developed vascular complications after MVD, focusing on their past medical history, perioperative laboratory findings and images, surgical findings, and postoperative progress.

RESULTS

Vascular complications developed in 28 patients (0.7%), including 24 with hemifacial spasm and 4 with trigeminal neuralgia. Twenty-two hemorrhagic (78.6%) and 6 ischemic (21.4%) complications occurred, with epidural hematoma the most frequent type identified. Ten patients (35.7%) patients were asymptomatic and 18 (64.3%) were symptomatic. Six patients (21.4%) underwent revision surgery, such as hematoma removal, craniectomy, or extraventricular drainage insertion. At the last follow-up, dizziness was the most commonly reported sequela from vascular complications. No deaths had occurred.

CONCLUSIONS

Vascular complications are rare, but can be the most devastating adverse outcome of MVD surgery. Unusual signs and symptoms after MVD should prompt special attention to early management and patient safety.

Seizure-like activities in patients with head-up tilt test-induced syncope

The purpose of this study was to assess the prevalence and the characteristics of seizure-like activities during head-up tilt test (HUT)-induced syncope, in patients with suspected vasovagal syncope (VVS). We also evaluated the differences in hemodynamic parameters between patients with and without seizure-like activities.A total of 71 patients with suspected VVS, who showed syncope during HUT between October 2010 and May 2013, were analyzed. Electrocardiogram and hemodynamic parameters were continuously monitored during HUT. We also performed video recording of patients during HUT to identify eyeball deviation or seizure-like limb movements.In all, 47 patients (66.2%) showed seizure-like activities at the time of syncope during HUT, 14 patients presented eyeball deviation, without abnormal limb movements, and 33 patients showed abnormal limb movements, such as myoclonic or tonic-clonic activities, as well as eyeball deviation. Upon comparison of the 2 groups with or without seizure-like activities, patients showing seizure-like activities presented a significantly lower heart rate at the time of syncope in HUT (38.51 ± 16.81 vs 49.67 ± 20.12, P < .05). Also, upon comparison within patients showing seizure-like activities, the patients who showed abnormal limb movements with eyeball deviation demonstrated a significantly lower systolic blood pressure and cardiac output at the time of syncope (34.30 ± 12.24 vs 49.00 ± 14.14, P < .05; 0.58 ± 0.40 vs 1.32 ± 0.97, P < .05).Seizure-like activities were observed in high percentage in about 66% of patients during HUT-induced syncope. The occurrence of seizure-like activities was associated with more severe transient hemodynamic changes, such as lower heart rate, systolic blood pressure, and cardiac output at the time of the HUT-induced syncope.

A surgical strategy to prevent delayed epidural hematoma after posterior fossa surgery using lateral suboccipital retrosigmoid approach

Although non-traumatic postoperative delayed epidural hematoma (EDH) after posterior fossa surgery is rare, measures to prevent it need to be pursued due to its catastrophic results. In this report, we describe a surgical strategy to prevent delayed EDH after posterior fossa surgery. Key dural tacking sutures were performed at the medial and cephalic margin of the dura. We have performed key dural tacking sutures on 454 patients with neurovascular compression syndrome during microvascular decompression surgeries since April 2016, and no hemorrhagic complication, including delayed EDH, occurred. We discovered that key dural tacking sutures can be helpful in preventing postoperative posterior fossa delayed EDH.

The pathogenesis of delayed epidural hematoma after posterior fossa surgery

The purpose of this study was to analyze the pathogenesis of delayed epidural hematoma (EDH) after posterior fossa surgery. Non-traumatic, non-arterial origin delayed EDH after posterior fossa surgery is extremely rare. Moreover, the pathogenesis of its supratentorial extension is obscure. Between April 1997 and June 2016, over 3300 patients underwent microvascular decompression (MVD) for neurovascular compression syndrome. The medical chart of four patients with delayed EDH were retrospectively reviewed. The median time from MVD to re-CT scan was 58 h (range, 33-100). All patients underwent hematoma evacuations. Intraoperative findings during hematoma evacuation revealed only an oozing hemorrhage from the transverse sinus with no definitive bleeding focus. The patients spent a median of 21.5 days (range, 11-39) at the hospital. At the last follow-up, all patients had fully recovered without significant neurological deficits and exhibited complete relief or minimal symptoms from hemifacial spasm (HFS). Postoperative uncontrolled bleeding from the dural venous sinus can sometimes cause an insidious-onset or delayed posterior fossa EDH.

Ultrasonographic and Electrophysiological Evaluation of Ulnar Nerve Instability and Snapping of the Triceps Medial Head in Healthy Subjects

OBJECTIVE

To evaluate the relationship between ulnar nerve instability and snapping of the triceps medial head during elbow flexion.

DESIGNS

Twenty-six healthy individuals were recruited. The primary outcome measures were ultrasonographic and electrophysiological parameters of the ulnar nerve. Ulnar nerve instability was classified into three types based on the degree of ulnar nerve movement: no dislocation (Type N), subluxation (Type S), and dislocation (Type D).

RESULTS

In the elbow 90-degree position, the incidences of Type N, S, and D were 41 (78.8%), 8 (15.4%), and 3 (5.8%) elbows, respectively; in the full flexion position, the incidences of Types N, S, and D were 24 (46.2%), 19 (36.5%), and 9 (17.3%) elbows, respectively. Spearman's correlation coefficients between ulnar nerve instability and snapping of the triceps medial head in the elbow 90-degree and full flexion positions were 0.808 and 0.889 (P < 0.001), respectively. The ulnar sensory response in Type S was of prolonged latency and decreased amplitude compared with that in Type N or D in the elbow full flexion position.

CONCLUSIONS

Ulnar nerve instability increased with elbow flexion and correlated with snapping of the triceps medial head. Ultrasonography of the ulnar nerve is an important tool in ulnar nerve instability assessment.

Real-time intraoperative monitoring of brainstem auditory evoked potentials during microvascular decompression for hemifacial spasm

OBJECTIVE The aim of this study was to define a new protocol for intraoperative monitoring (IOM) of brainstem auditory evoked potentials (BAEPs) during microvascular decompression (MVD) surgery to treat hemifacial spasm (HFS) and to evaluate the usefulness of this new protocol to prevent hearing impairment. METHODS To define the optimal stimulation rate, estimate the number of trials to be averaged, and identify useful warning criteria in IOM of BAEPs, the authors performed a preliminary study of 13 patients with HFS in 2010. They increased the stimulation rate from 10.1 Hz/sec to 100.1 Hz/sec by 10-Hz increments, and they elevated the average time from 100 times to 1000 times by 100-unit increments at a fixed stimulus rate of 43.9 Hz. After defining the optimal stimulation rate and the number of trials that needed to be averaged for IOM of BAEPs, they also identified the useful warning criteria for this protocol for MVD surgery. From January to December 2013, 254 patients with HFS underwent MVD surgery following the new IOM of BAEPs protocol. Pure-tone audiometry and speech discrimination scoring were performed before surgery and 1 week after surgery. To evaluate the usefulness of the new protocol, the authors compared the incidence of postoperative hearing impairment with the results from the group that underwent MVD surgery prior to the new protocol. RESULTS Through a preliminary study, the authors confirmed that it was possible to obtain a reliable wave when using a stimulation rate of 43.9 Hz/sec and averaging 400 trials. Only a Wave V amplitude loss > 50% was useful as a warning criterion when using the new protocol. A reliable BAEP could be obtained in approximately 9.1 seconds. When the new protocol was used, 2 patients (0.8%) showed no recovery of Wave V amplitude loss > 50%, and only 1 of those 2 patients (0.39%) ultimately had postoperative hearing impairment. When compared with the outcomes in the pre-protocol group, hearing impairment incidence decreased significantly among patients who underwent surgery with the new protocol (0.39% vs 4.02%, p = 0.002). There were no significant differences between the 2 surgery groups regarding other complications, including facial palsy, sixth cranial nerve palsy, and vocal cord palsy. CONCLUSIONS There was a significant decrease in postoperative hearing impairment after MVD for HFS when the new protocol for IOM of BAEPs was used. Real-time IOM of BAEPs, which can obtain a reliable BAEP in less than 10 seconds, is a successful new procedure for preventing hearing impairment during MVD surgery for HFS.

Mesial Temporal Lobe Epilepsy in Congenital Toxoplasmosis: A Case Report

Toxoplasmosis is a rare disease caused by intracellular protozoan parasite, Toxoplasma gondii. Though most patients with toxoplasmosis are asymptomatic, congenital toxoplasmosis in the fetus can cause ocular involvement such as chorioretinitis and central nervous system disease including intracerebral calcification, nystagmus, hydrocephalus and microcephaly. Also, these brain lesions can cause seizure secondarily. Our patient was diagnosed with congenital toxoplasmosis, based on toxoplasma-specific serologic test with typical clinical symptoms, including chorioretinitis, nystagmus, hydrocephalus and cerebral palsy. Her brain imaging findings revealed not only the multifocal encephalomalacia, but also multifocal cerebral calcification including intracerebral calcification in left perihippocampal region. Her epileptogenic zone was defined as mesial temporal lobe including hippocampus on left side by seizure semiology, electroencephalogram and neuroimaging including single photon emission computed tomography and 18F-Fluorodeoxyglucose positron-emission tomography. Her seizures were refractory to multiple anti-epileptic drugs. We report a patient with congenital toxoplasmosis who showed intractable mesial temporal lobe epilepsy.

Usefulness of phrenic latency and forced vital capacity in patients with ALS with latent respiratory dysfunction

OBJECTIVES

The pulmonary function test (PFT) is a non-invasive and easily available technique to assess respiratory function in patients with amyotrophic lateral sclerosis (ALS); however, patients with dyspnea sometimes show normal PFT findings. Herein, we investigated whether phrenic nerve conduction study (NCS) and PFT are useful to evaluate respiratory function of patients with ALS with normal value ranges in the PFT.

METHODS

We prospectively enrolled 34 patients with definite or probable ALS, who showed FVC (%) ⩾80 of predicted and 78 healthy subjects. PFT and phrenic NCS were performed with the measurement of forced vital capacity (FVC, %), forced expiratory volumes in 1s (FEV1, %), FEV1/FCV ratio (%), and phrenic compound muscle action potential amplitude, and latency.

RESULTS

Compared to healthy controls, ALS patients showed delayed phrenic nerve latency and the decrease of FVC (%) (p=0.006 and p<0.0001, respectively). ROC curve analysis demonstrated that phrenic latency (AUC=0.7655) and FVC (%) (AUC=0.8239) discriminated ALS patients from healthy subjects.

CONCLUSION

We demonstrated that ALS patients had early respiratory dysfunction, despite normal PFT findings.

SIGNIFICANCE

Phrenic latency and FVC (%) can be helpful to discriminate ALS patients with latent respiratory dysfunction from healthy subjects.

Low levels of vitamin D in neuromyelitis optica spectrum disorder: association with disease disability

Patients with autoimmune disorders often have low levels of 25-hydroxyvitamin D [25(OH)D3], which correlates with disability or disease activity. Vitamin D may play a role in neuromyelitis optica (NMO) or NMO spectrum disorder (NMOSD), as an important factor involved in immunological pathways. We investigated the relationship between vitamin D levels and disease related disability and clinical activity in patients with NMOSD. Blood samples from 51 patients with NMOSD who were positive for anti-aquaporin4-antibody (AQP4-ab) and 204 healthy controls were collected for 25(OH)D3 measurement. Clinical parameters, including expanded disability status scale (EDSS) score, annualized relapse rate (ARR) and time of blood sampling relative to attack, were determined in patients with NMOSD. We found that 25(OH)D3 levels were significantly lower in patients with NMOSD compared to healthy controls. There was no difference between 25(OH)D3 levels in blood samples taken at relapse or remission, and no association between 25(OH)D3 levels and ARR, but there was an inverse correlation between 25(OH)D3 levels and EDSS scores in patients with NMOSD. It remains to be determined whether low vitamin D levels predispose to NMO and/or modify disease severity, or are secondary to neurological disability. In either case the results could also be of relevance to other neurological diseases such as multiple sclerosis as well as NMO.