Y Stenting in Wide-Necked Bifurcation Aneurysms: A Single-Center Experience

Stent-assisted coiling is an endovascular means of managing wide-necked bifurcation aneurysms. In spite of the wide availability of various newer devices in managing such difficult aneurysms, the Y stenting offers a safe and cost-effective alternative to treat such cases in resource poor settings. This article provides an insight of our initial six cases of Y stent-assisted coiling along with their follow-up over a period of 6 months with no recanalization in any case. It also highlights the various technical aspects involved in such cases. One case had recurrent subdural hematoma probably due to use of antiplatelets and another patient had sudden dip in level of consciousness probably due to hematoma expansion that might also have been due to antiplatelet usage. However, none of the cases had any issues regarding stent migration, malapposition, and dissection. In our experience, Neuroform Atlas stent used for Y stenting offers a safe and technically easy alternative to various newer bifurcation devices.

Clinical Problem Solving: Decreased Level of Consciousness and Unexplained Hydrocephalus

We present a clinical reasoning case of 42-year-old male with a history of type 1 diabetes who presented to hospital with decreased level of consciousness. We review the approach to coma including initial approach to differential diagnosis and investigations. After refining the diagnostic options based on initial investigations, we review the clinical decision-making process with a focus on narrowing the differential diagnosis, further investigations, and treatment.

Intraoperative hand strength as an indicator of consciousness during awake craniotomy: a prospective, observational study

Awake craniotomy enables mapping and monitoring of brain functions. For successful procedures, rapid awakening and the precise evaluation of consciousness are required. A prospective, observational study conducted to test whether intraoperative hand strength could be a sensitive indicator of consciousness during the awake phase of awake craniotomy. Twenty-three patients who underwent awake craniotomy were included. Subtle changes of the level of consciousness were assessed by the Japan Coma Scale (JCS). The associations of hand strength on the unaffected side with the predicted plasma concentration (Cp) of propofol, the bispectral index (BIS), and the JCS were analyzed. Hand strength relative to the preoperative maximum hand strength on the unaffected side showed significant correlations with the Cp of propofol (ρ = − 0.219, p = 0.007), the BIS (ρ = 0.259, p = 0.002), and the JCS (τ = − 0.508, p = 0.001). Receiver operating characteristic curve analysis for discriminating JCS 0–1 and JCS ≥ 2 demonstrated that the area under the curve was 0.76 for hand strength, 0.78 for Cp of propofol, and 0.66 for BIS. With a cutoff value of 75% for hand strength, the sensitivity was 0.76, and the specificity was 0.67. These data demonstrated that hand strength is a useful indicator for assessing the intraoperative level of consciousness during awake craniotomy.

Statistical learning in patients in the minimally conscious state

When listening to an unknown language, listeners could learn the transitional probability between syllables and group frequently co-occurred syllables into a whole unit. Such statistical learning ability has been demonstrated for both pre-verbal infants and adults, even during passive listening. Here, we investigated whether statistical learning occurred in patients in minimally conscious state (MCS) and patients emerged from the minimally conscious state (EMCS) using electroencephalography (EEG). We presented to participants an isochronous sequence of syllables, which were composed of either 2-word real phrases or 2-word artificial phrases that were defined by the transitional probability between words. An inter-trial phase coherence (ITPC) analysis revealed that the phrase-rate EEG response was weakened in EMCS patients compared with healthy individuals, and was even more severely weakened in MCS patients. Although weak, the phrase-rate response or its harmonics remained statistically significant in MCS patients, suggesting that the statistical learning ability was preserved in MCS patients. The word-rate response was also weakened with a decreased level of consciousness. The harmonics of the word-rate response, however,were more salient in MCS than EMCS patients in the alpha and beta bands. Together with previous studies, the current results suggest that MCS patients retain residual learning ability, which can potentially be harnessed to induce neural plasticity, and that different frequency bands are differentially related to the consciousness level.

Continuous Incisional Lidocaine in Pediatric Patients following Open Heart Surgery

Continuous incisional lidocaine infusion has been proposed as an adjunctive therapy in the management of postoperative pain in adult patients. The aim of this study was to determine the efficacy and safety of a continuous subcutaneous lidocaine infusion in pediatric patients following open heart surgery. All patients receiving a subcutaneous lidocaine infusion in median sternotomy incisions after open heart surgery during 2 consecutive years were included in the study. A historical cohort of patients was used as a control group. Demographic variables (age, size, and surgical procedure), variables related to sedation and analgesia (COMFORT and analgesia scales, drug doses, and duration), and complications were registered. 106 patients in the lidocaine infusion group and 79 patients in the control group were included. Incisional analgesia was effective for the treatment of pain as it reduced the dose and duration of intravenous fentanyl (odds ratio (OR) 6.26, confidence interval (CI) 95%: 2.48-15.97, p = 0.001 ; OR 4.30, CI 95%: 2.09-8.84, p = 0.001 , respectively). The reduction in fentanyl use was more important in children over two years of age. Adverse effects were seen in three children (2.8%): they all had decreased level of consciousness, and one of them presented seizures as well. Two of these three patients had lidocaine levels over 2 mcg/ml. A continuous lidocaine incisional infusion is effective for the treatment of pain after open heart surgery. This procedure reduced intravenous analgesic drug requirements in pediatric patients undergoing a median sternotomy incision. Although the incidence of secondary effects is low, monitoring of neurologic status and lidocaine blood levels are recommended in all patients.

Primary adipsia and severe hypernatremia in a Pit Bull dog

ABSTRACT: Primary adipsia is a rare condition in which there is failure in the activation threshold of the hypothalamic osmoreceptors, leading to osmolality imbalance. Here, we reported the case of a Pit Bull dog with an altered level of consciousness (started after weaning) and adipsia. There was an increase in plasma osmolality (444 mOsm/kg), sodium (223.7 mg/dL), and chlorine (173 mg/dL) levels. Based on the suspicion of primary adipsia, water was administered via a nasogastric tube, with clinical improvement. The owner was instructed to supply water with food. Eight months after discharge, the dog returned with parvovirus and died. In the anatomopathological examination, no structural changes were observed in the central nervous system. To our knowledge, this is the first report of hypernatremia due to adipsia in a Pit Bull dog, showing that this is a differential diagnosis that should be considered in this breed.

Neurologic Complications in Adult and Pediatric Patients with SARS-CoV-2 Infection

SARS-CoV-2 has an impact on the nervous system as a result of pathological cellular and molecular events at the level of vascular and neural tissue. Severe neurologic manifestations including stroke, ataxia, seizure, and depressed level of consciousness are prevalent in patients with SARS-CoV-2 infection. Although the mechanism is still unclear, SARS-CoV-2 has been associated with the pathogenesis of intravascular coagulation and angiotensin-converting enzyme-I, both exacerbating systemic inflammation and contributing to hypercoagulation or blood–brain barrier leakage, resulting in ischemic or hemorrhagic stroke. On the other hand, the SARS-CoV-2 spike protein in neural tissue and within the cerebrospinal fluid may induce neural dysfunction, resulting in neuroinflammation, which is exacerbated by peripheral and neural hypercytokinemia that can lead to neuronal damage and subsequent neuroinflammation. A deeper understanding of the fundamental biological mechanisms of neurologic manifestations in SARS-CoV-2 infection can pave the way to identifying a single biomarker or network of biomarkers to help target neuroprotective therapy in patients at risk for developing neurological complications.

Predictors of prolonged hospitalisation and mortality among children admitted with blackwater fever in eastern Uganda

Our study aimed at determining clinical factors associated with prolonged hospitalisation and death among children admitted with blackwater fever (BWF). We analysed 920 eligible records for the period January – December 2018 from Mbale and Soroti Regional Referral Hospitals in Eastern Uganda. The median hospitalisation was 3 (IQR: 2–5 days) days. Prolonged hospitalisation was in 251/920 (27.3%). Clinical features independently associated with prolonged hospitalisation included abdominal tenderness, body pain and mild fever. 29/920 (3.2%) died, of these 20 (69.0%) within 48 h of admission. Features of severity associated with mortality were noisy or interrupted breathing, tachypnoea, chest pain, convulsions, delayed capillary refill time (≥3 s), severe pallor, high fever (>38.5°C), altered level of consciousness, prostration and acidotic breathing.