Teena Shetty

A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms.

BACKGROUND: Visualization with ultrasound during regional anesthesia may reduce the risk of intraneural injection and subsequent neurological symptoms but has not been formally assessed. Thus, we performed this randomized clinical trial comparing ultrasound versus nerve stimulator-guided interscalene blocks for shoulder arthroscopy to determine whether ultrasound could reduce the incidence of postoperative neurological symptoms. METHODS: Two hundred thirty patients were randomized to a standardized interscalene block with either ultrasound or nerve stimulator with a 5 cm, 22 g Stimuplex® insulated needle with 1.5% mepivacaine with 1:300,000 epinephrine and NaCO3 (1 meq/10 mL). A standardized neurological assessment tool (questionnaire and physical examination) designed by a neurologist was administered before surgery (both components), at approximately 1 wk after surgery (questionnaire), and at approximately 4–6 weeks after surgery (both components). Diagnosis of postoperative neurological symptoms was determined by a neurologist blinded to block technique. RESULTS: Two hundred nineteen patients were evaluated. Use of ultrasound decreased the number of needle passes for block performance (1 vs 3, median, P < 0.001), enhanced motor block at the 5-min assessment (P = 0.04) but did not decrease block performance time (5 min for both). No patient required conversion to general anesthesia for failed block, and patient satisfaction was similar in both groups (96% nerve stimulator and 92% ultrasound). The incidence of postoperative neurological symptoms was similar at 1 wk follow-up with 11% (95% CI of 5%–17%) for nerve stimulator and 8% (95% CI of 3%–13%) for ultrasound and was similar at late follow-up with 7% (95% CI of 3%–12%) for nerve stimulator and 6% (95% CI of 2%–11%) for ultrasound. The severity of postoperative neurological symptoms was similar between groups with a median patient rating of moderate. Symptoms were primarily sensory and consisted of pain, tingling, or paresthesias. CONCLUSIONS: Ultrasound reduced the number of needle passes needed to perform interscalene block and enhanced motor block at the 5 min assessment; however, we did not observe significant differences in block failures, patient satisfaction or incidence, and severity of postoperative neurological symptoms.

A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery.

BACKGROUND: There is a lack of clinical registries to document efficacy and safety of ultrasound-guided regional anesthesia. Interscalene blocks are effective for shoulder arthroscopy, and ultrasound guidance may reduce risk. Furthermore, ultrasound-guided supraclavicular block is a novel approach for shoulder anesthesia that may have less risk for neurological symptoms than interscalene block. METHODS: One thousand one hundred sixty-nine patients undergoing ultrasound-guided regional anesthesia for ambulatory shoulder arthroscopy were enrolled in our prospective registry. Standardized perioperative data were collected including a preoperative neurological screening tool. Either interscalene or supraclavicular block was performed at the discretion of the clinical team. Standardized follow-up was performed in the postanesthesia care unit and at 1 week. Postoperative neurological symptoms (PONS) were assessed at the 1-week follow-up with the same screening tool by a blinded neurologist. RESULTS: Ultrasound-guided interscalene (n = 515) and supraclavicular (n = 654) blocks had excellent anesthetic success (99.8%; 95% confidence interval [CI], 99.4%–99.9%) with 0% (95% CI, 0%–0.3%) incidence of vascular puncture or intravascular injection. The incidence of hoarseness in the postanesthesia care unit was significantly less with supraclavicular (22% with 95% CI, 19%–26%) than interscalene block (31% with 95% CI, 27%–35%). The incidence of dyspnea was similar (7% for supraclavicular vs 10% with interscalene). No patient had a clinically apparent pneumothorax. The incidence of PONS was very low (0.4% with 95% CI, 0.1%–1%), and there was a 0% (95% CI, 0%–0.3%) incidence of permanent nerve injury. CONCLUSIONS: Ultrasound-guided interscalene and supraclavicular blocks are effective and safe for shoulder arthroscopy. Temporary and permanent PONS is uncommon.

Chordoid glioma: report of a case with unusual histologic features, ultrastructural study and review of the literature

Chordoid gliomas are an uncommon primary brain tumor with histologic features of a chordoma and immunolabeling for glial fibrillary acid protein. We report the 32nd case with a review of the literature. The clinical, radiographic and pathologic features of the tumor are presented with new pathologic findings adding support that this lesion may be of ependymal origin. Treatment and long term outcome are limited but chordoid gliomas appear to be indolent lesions that may be cured with gross total resection.

Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015

BACKGROUND Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment. OBJECTIVE To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion. METHODS On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device. RESULTS A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%. CONCLUSION Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments. ABBREVIATIONS ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

The Bear Fedio Inventory: Twenty years on

In this paper, literature on the Bear Fedio Inventory is reviewed. In particular, studies attempt to distinguish a temporal lobe subgroup and studies of laterality. In conclusion, the Bear Fedio Inventory does more than measure general psychopathology, but that the clinimetrics, in particular test reliability and responsiveness, need to be further examined. Laterality differences have not held up over time, although patients with left-sided lesions tend to report higher scores more consistently that those with right-sided lesions

Transient aphasia and reversible major depression due to a giant sagittal sinus dural AV fistula

A 61-year-old man presenting with transient global aphasia and chronic major depression was found to have a giant high flow dural arteriovenous fistula of the superior sagittal sinus. EEG and SPECT scan showed left frontoparietal dysfunction. This resolved after fistula embolization, as did the patient’s neuropsychiatric complaints.

Recursive feature elimination for biomarker discovery in resting-state functional connectivity

Biomarker discovery involves finding correlations between features and clinical symptoms to aid clinical decision. This task is especially difficult in resting state functional magnetic resonance imaging (rs-fMRI) data due to low SNR, high-dimensionality of images, inter-subject and intra-subject variability and small numbers of subjects compared to the number of derived features. Traditional univariate analysis suffers from the problem of multiple comparisons. Here, we adopt an alternative data-driven method for identifying population differences in functional connectivity. We propose a machine-learning approach to down-select functional connectivity features associated with symptom severity in mild traumatic brain injury (mTBI). Using this approach, we identified functional regions with altered connectivity in mTBI. including the executive control, visual and precuneus networks. We compared functional connections at multiple resolutions to determine which scale would be more sensitive to changes related to patient recovery. These modular network-level features can be used as diagnostic tools for predicting disease severity and recovery profiles.

Imaging in Chronic Traumatic Encephalopathy and Traumatic Brain Injury

Context: The diagnosis of chronic traumatic encephalopathy (CTE) can only be made pathologically, and there is no concordance of defined clinical criteria for premorbid diagnosis. The absence of established criteria and the insufficient imaging findings to detect this disease in a living athlete are of growing concern. Evidence Acquisition: The article is a review of the current literature on CTE. Databases searched include Medline, PubMed, JAMA evidence, and evidence-based medicine guidelines Cochrane Library, Hospital for Special Surgery, and Cornell Library databases. Study Design: Clinical review. Level of Evidence: Level 4. Results: Chronic traumatic encephalopathy cannot be diagnosed on imaging. Examples of imaging findings in common types of head trauma are discussed. Conclusion: Further study is necessary to correlate the clinical and imaging findings of repetitive head injuries with the pathologic diagnosis of CTE.

Risk factors for acute nerve injury after total knee arthroplasty: Acute Nerve Injury after TKA

Introduction: In this we study identified potential risk factors for post−total knee arthroplasty (TKA) nerve injury, a catastrophic complication with a reported incidence of 0.3%−1.3%. Methods: Patients who developed post‐TKA nerve injury from 1998 to 2013 were identified, and each was matched with 2 controls. A multivariable logistic regression model was built to calculate odds ratios (ORs). Results: Sixty‐five nerve injury cases were identified in 39,990 TKAs (0.16%). Females (OR 3.28, P = 0.003) and patients with history of lumbar pathology (OR 6.12, P = 0.026) were associated with increased risk of nerve injury. Tourniquet pressure < 300 mm Hg and longer duration of anesthesia may also be risk factors. Discussion: Surgical planning for females and patients with lumbar pathology should be modified to mitigate their higher risk of neurologic complications after TKA. Our finding that lower tourniquet pressure was associated with higher risk of nerve injury was unexpected and requires further investigation. Muscle Nerve 57: 946–950, 2018

Longitudinal Resting State Functional Connectivity Predicts Clinical Outcome in Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) affects about 42 million people worldwide. It is often associated with headache, cognitive deficits, and balance difficulties but rarely shows any abnormalities on conventional computed tomography (CT) or magnetic resonance imaging (MRI). Although in most mTBI patients the symptoms resolve within 3 months, 10-15% of patients continue to exhibit symptoms beyond a year. Also, it is known that there exists a vulnerable period post-injury, when a second injury may exacerbate clinical prognosis. Identifying this vulnerable period may be critical for patient outcome, but very little is known about the neural underpinnings of mTBI and its recovery. In this work, we used advanced functional neuroimaging to study longitudinal changes in functional organization of the brain during the 3-month recovery period post-mTBI. Fractional amplitude of low frequency fluctuations (fALFF) measured from resting state functional MRI (rs-fMRI) was found to be associated with symptom severity score (SSS, r = -0.28, p = 0.002). Decreased fALFF was observed in specific functional networks for patients with higher SSS, and fALFF returned to higher values when the patient recovered (lower SSS). In addition, functional connectivity of the same networks was found to be associated with concurrent SSS, and connectivity immediately after injury (<10 days) was capable of predicting SSS at a later time-point (3 weeks to 3 months, p < 0.05). Specific networks including motor, default-mode, and visual networks were found to be associated with SSS (p < 0.001), and connectivity between these networks predicted 3-month clinical outcome (motor and visual: p < 0.001, default-mode: p < 0.006). Our results suggest that functional connectivity in these networks comprise potential biomarkers for predicting mTBI recovery profiles and clinical outcome.