Ellen Deibert

Mechanical ventilation for ischemic stroke and intracerebral hemorrhage: Indications, timing, and outcome

Objective: To compare the incidence, indication, and timing of intubation and outcome in patients with cerebral infarction (ISCH) and intracerebral hemorrhage(HEM) requiring mechanical ventilation (MV). Background: Poor outcomes have been reported for ISCH patients requiring MV. Because the target population, pathophysiology, and management of ISCH and HEM patients differ considerably, we compared the characteristics of patients with ISCH and HEM who required MV. Methods: A retrospective review of ISCH and HEM stroke patients who underwent MV at a tertiary care academic center from 1994 to 1997 was performed to determine age, sex, type, and location of stroke (anterior or posterior circulation); brainstem dysfunction at intubation (pupillary, corneal, and oculocephalic reflexes); indication for intubation (neurologic deterioration, cardiopulmonary deterioration, or elective intubation for surgery); timing of intubation (on presentation or later); comorbidities; and outcome (hospital disposition). Results: A total of 230 patients, 74 with ISCH and 156 with HEM (mean age, 61± 16 years; male-to-female ratio, 1.15:1), underwent MV. Intubation rates were 6% for ISCH patients and 30% for HEM patients. Two-thirds of the patients required intubation on presentation (84% were intubated for neurologic deterioration) and 131 patients (57%) died (ISCH, 55%; HEM, 58%). Signs of brainstem dysfunction predicted a higher mortality for both groups. Additionally, early intubation and older age predicted mortality for HEM, and male gender predicted mortality in ISCH. Stroke location and comorbidities did not influence outcome. Conclusions: MV in acute stroke is associated with high mortality. Mortality and outcome were similar for ISCH and HEM; however, the factors predictive of outcome may differ and influence decisions about the use of MV in such patients.

Neural pathways in tactile object recognition.

Objective: To define further the brain regions involved in tactile object recognition using functional MRI (fMRI) techniques. Background: The neural substrates involved in tactile object recognition (TOR) have not been elucidated. Studies of nonhuman primates and humans suggest that basic motor and somatosensory mechanisms are involved at a peripheral level; however, the mechanisms of higher order object recognition have not been determined. Methods: The authors investigated 11 normal volunteers utilizing fMRI techniques in an attempt to determine the neural pathways involved in TOR. Each individual performed a behavioral paradigm with the activated condition involving identification of objects by touch, with identification of rough/smooth as the control. Results: Data suggest that in a majority of individuals, TOR involves the calcarine and extrastriatal cortex, inferior parietal lobule, inferior frontal gyrus, and superior frontal gyrus–polar region. Conclusions: TOR may utilize visual systems to access an internal object representation. The parietal cortices and inferior frontal regions may be involved in a concomitant lexical strategy of naming the object being examined. Frontal polar activation likely serves a role in visuospatial working memory or in recognizing unusual representations of objects. Overall, these findings suggest that TOR could involve a network of cortical regions subserving somatosensory, motor, visual, and, at times, lexical processing. The primary finding suggests that in this normal study population, the visual cortices may be involved in the topographic spatial processing of TOR.

Reversible left ventricular dysfunction associated with raised troponin I after subarachnoid haemorrhage does not preclude successful heart transplantation

Transient abnormalities in ECGs, echocardiograms, and cardiac enzymes have been described in the acute setting of subarachnoid haemorrhage. In addition, left ventricular dysfunction has been reported at the time of brain death. A patient with an acute subarachnoid haemorrhage who presented with raised troponin I (TnI) concentrations and diffuse left ventricular dysfunction is described. After declaration of brain death 32 hours later, the heart was felt initially not suitable for transplantation. A normal cardiac catheterisation, however, lead to successful transplantation of the donor heart. Raised catecholamine concentrations and metabolic perturbations have been proposed as the mechanisms leading to the cardiac dysfunction seen with brain death. This may be a biphasic process, allowing time for myocardial recovery and reversal of the left ventricular dysfunction. Awareness of this phenomenon in the acutely ill neurologic population needs to be raised in order to prevent the unnecessary rejection of donor hearts.

How many HITS are too many? The use of accelerometers to study sports-related concussion

Concussion is a common contact sports injury. There is growing concern that repetitive head trauma can lead to the pathologic findings associated with chronic traumatic encephalopathy (CTE), a progressive neurodegenerative process leading to pronounced behavior and cognitive dysfunction.(1) Ideally, clinicians would have a way to predict CTE and prevent it in our athletes. Language: en

Lesion analysis in mild traumatic brain injury Old school goes high tech

Concussion has been a controversial topic in neurology since the beginning of the discipline. Evidence-based diagnostic guidelines have been established,1 but the diagnosis and treatment are largely grounded in clinical decision-making. Clinical and research issues around sports concussion have even reached the levels of government policy with the White House Healthy Kids & Safe Sports Concussion Summit (May 29, 2014), recently held by President Obama. The field needs objective answers to questions about mild traumatic brain injury (mTBI), its effects, treatment resolution, or long-term sequelae that may only be answered by development of objective measures of mTBI.

When is a concussion no longer a concussion

Concussion has been in the medical lexicon since Hippocrates,1 and widespread viewing of sports concussion is now commonplace. This mildest form of traumatic brain injury (TBI) has obvious acute effects, but motor symptoms seem to abate quickly as the concussed player leaves the contest. The prompt return to baseline in most sports concussions could be considered as evidence for the transient nature of the injury, with the brains homeostatic equilibrium temporarily disrupted and then restored, but this view may be changing. With 1.6–3.8 million sports-related concussions annually in the United States (http://www.cdc.gov/ncipc/tbi/Physician_Tool_Kit), the possible long-term consequences of concussion clearly merit attention.

Management of Adults with Traumatic Brain Injury

Management of Adults with Traumatic Brain Injury is a well-written, comprehensive, and succinct guide to the treatment of individuals who have had a traumatic brain injury. The objective of the book is “to provide physicians, psychologists, nurses, and mental health and rehabilitation specialists with concise and practical guidance on the clinical management of individuals and families affected by traumatic brain injury.” This book clearly meets this objective.

Concussion and the neurologist A work in progress

In the last 3 decades, the neurology landscape has changed. Once primarily an academic profession with limited treatment options, neurology now is a clinical field with treatments available in the acute care setting. Treatment of an acute ischemic stroke may begin with tissue plasminogen activator given in the emergency room within 4.5 hours of symptoms.1 This clinical shift now includes the evaluation and management of concussion patients. With the current estimate from the Centers for Disease Control and Prevention being 1.6–3.8 million sports- and recreation-related concussions per year (up from the prior estimate of 300,000), more neurologists will be asked to evaluate these patients.2,3