Frontiers in Neurology最新文献

Introduction: In the past decade, flow diverters (FDs) have increasingly been used to treat cerebral aneurysms with unfavorable morphology in which other endovascular techniques fall short of being as effective. In-stent stenosis (ISS) is one of the most puzzling and frequent risks of flow diversion therapy observed on follow-ups. This complication, although mostly placid in its clinical course, can have dire consequences if patients become symptomatic. ISS is associated with many factors, none of which have been demonstrated to date to be solely responsible for the phenomenon.

Methods: This study was aimed at evaluating ISS incidence in patients in our clinic who were treated with flow-diverters for aneurysms, located on the supraclinoid segments of the internal carotid artery between September 2022 and May 2023. A retrospective analysis was conducted, which included 137 patients with a total of 142 aneurysms being treated. The main hypothesis was that oversizing of the implant might play a role in ISS development. The performed statistical analysis, aimed at finding a correlation between it and vessel lumen narrowing on the follow-ups. The effects of other known risk factors, such as sex, age, smoking, and hypertension, were also analyzed.

Results: Stent oversizing with respect to the parent artery was positively correlated with subsequent ISS occurrence and severity. Older age was a protective factor against ISS. Patients who actively smoked had diminished risk of developing severe ISS.

Discussion: Stent oversizing can lead to ISS development, which might be more pronounced with larger implant-to-vessel sizing discrepancies. To achieve optimal results, the choice of implant diameter should consider all segments of the vessel in which it will be implanted. In cases of severe symptomatic ISS, continuation of dual anti-platelet therapy is a reasonable and effective option to address this complication.

Introduction: Freezing of gait (FOG) is a disabling symptom for people with Parkinson's disease (PwPD). Turning on the spot for one minute in alternating directions (360 turn) while performing a cognitive dual-task (DT) is a fast and sensitive way to provoke FOG. The FOG-index is a widely used wearable sensor-based algorithm to quantify FOG severity during turning. Despite that, the FOG-index's classification performance and criterion validity is not tested against the gold standard (i.e., video-rated time spent freezing). Therefore, this study aimed to evaluate the FOG-index's classification performance and criterion validity to assess FOG severity during 360 turn. Additionally, we investigated the FOG-index's optimal cutoff values to differentiate between PwPD with and without FOG.

Methods: 164 PwPD self-reported the presence of FOG on the New Freezing of Gait Questionnaire (NFOGQ) and performed the DT 360 turn in the ON medication state while being videoed and wearing five wearable sensors. Two independent clinical experts rated FOG on video. ROC-AUC values assessed the FOG-index's classification accuracy against self-reported FOG and expert ratings. Spearman-rho was used to evaluate the correlation between expert and FOG-index ratings of FOG severity.

Results: Twenty-eight patients self-reported FOG, while 104 were classified as a freezer by the experts. The FOG-index had limited classification agreement with the NFOGQ (AUC = 0.60, p = 0.115, sensitivity 46.4%, specificity 72.8%) and the experts (AUC = 0.65, p < 0.001, sensitivity 68.3%, specificity 61.7%). Only weak correlations were found between the algorithm outputs and expert ratings for FOG severity (rho = 0.13-0.38).

Conclusion: A surprisingly large discrepancy was found between self-reported and expert-rated FOG during the 360 turning task, indicating PwPD do not always notice FOG in daily life. The FOG-index achieved suboptimal classification performance and poor criterion validity to assess FOG severity. Regardless, 360 turning proved a sensitive task to elicit FOG. Further development of the FOG-index is warranted, and long-term follow-up studies are needed to assess the predictive value of the 360 turning task for classifying FOG conversion.

Introduction: Chlorfenapyr, a broad-spectrum insecticide and acaricide of the pyrrole-class pesticides, can induce dizziness, fatigue, profuse sweating, and altered consciousness by interfering with cell energy metabolism. However, chlorfenapyr-related rhabdomyolysis has rarely been reported.

Case presentations: Patient 1 was a healthy 26-year-old man who ingested approximately 30 mL of chlorfenapyr. After gastric lavage, rehydration, diuresis, liver protection, and symptomatic treatment, he was discharged. However, he was readmitted 11 days later with rhabdomyolysis and acute kidney injury, and his blood tralopyril level was 187 μg/mL. Patient 2 was a 43-year-old man who consumed approximately 50 mL of chlorfenapyr without seeking medical care for 6 days. On day 7, his blood chlorfenapyr and tralopyril levels were 42 μg/mL and 542 μg/mL, respectively. Subsequently, the patient was diagnosed with rhabdomyolysis and brainstem injury.

Discussion: Chlorfenapyr can disrupt cellular energy metabolism, leading to rhabdomyolysis and brainstem injury, and physical activity may trigger and accelerate rhabdomyolysis. The delayed damage caused by chlorfenapyr poisoning may be attributed to the gradual depletion of cellular energy and prolonged presence of its metabolites in the body.

Objective: To assess the changes of thalamic metabolites before and after surgery in patients with Cervical Spondylotic Myelopathy (CSM) using Hydrogen Proton Magnetic Resonance Spectroscopy (¹H-MRS) and to investigate its association with improvement in neurological function.

Methods: Forty-eight CSM patients who underwent cervical decompression surgery from December 2022 to June 2023 were included, and 33 healthy volunteers were recruited. All subjects underwent bilateral thalamic ¹H-MRS scans before the surgical procedure, and subsequently again 6 months later. Neurological function was assessed pre-operatively and post-operatively (6 months) in all patients with CSM using the modified Japanese Orthopedic Association (mJOA). The changes of mJOA (ΔmJOA = postoperative mJOA-preoperative mJOA) were employed as an indicator of neurological improvement. The pre- and postoperative metabolic ratio of N-acetylaspartate/creatine (NAA/Cr), choline/creatine (Cho/Cr), myo-inositol/creatine (mI/Cr), glutamate and glutamine complex/creatine (Glx/Cr) were statistically compared in CSM patients and healthy controls (HCs). A correlation analysis was conducted to determine the relationship between alterations in pre- and postoperative metabolite ratios (ΔNAA/Cr, ΔCho/Cr, ΔmI/Cr, ΔGlx/Cr) and ΔmJOA.

Results: Compared to the HCs, patients with CSM showed significantly lower pre- and post-operative NAA/Cr (Z = -4.235, p < 0.001; Z = -3.184, p = 0.001), Cho/Cr (Z = -5.050, p < 0.001; (Z = -2.624, p = 0.007) and mI/Cr (Z = -3.739, p = 0.001; Z = -2.014, p = 0.044). There was no difference in Glx/Cr between patients in patients with CSM, either preoperatively or postoperatively, compared to HCs. Post-operative NAA/Cr (Z  = -2.285, p = 0.041) and mI/Cr (Z = -2.925, p = 0.021) were increased in CSM patients compared to pre-operative NAA/Cr and mI/Cr. In CSM patients, ΔmI/Cr correlated significantly with ΔmJOA (r = 0.507, p < 0.001).

Conclusion: The preliminary findings indicate that metabolites in the thalamus of CSM patients exhibit changes following surgery. Additionally, it has been demonstrated that elevated postoperative mI correlates with improvements in neurological function.

Background: Essential tremor (ET) is the most common neurological movement disorder with few treatments and limited therapeutic efficacy, research into noninvasive and effective treatments is critical. Abnormal cerebello-thalamo-cortical (CTC) loop function are thought to be significant pathogenic causes of ET, with the cerebellum and cortex are common targets for ET treatment. In recent years, transcranial magnetic stimulation (TMS) has been recognized as a promising brain research technique owing to its noninvasive nature and safety. In this study, we will use left M1 cortex continuous theta-burst stimulation (cTBS) combined with right cerebellar hemisphere 1 Hz repetitive transcranial magnetic stimulation (rTMS) dual-target stimulation to explore the Safety, feasibility and efficiency of this dual-target stimulation mode, and the mechanism of its therapeutic effect.

Methods: Twenty-four patients with ET will be randomly assigned to three groups: dual-target stimulation, single-target stimulation, or sham stimulation. The single-target stimulation group will receive stimulation of the right cerebellar hemisphere for 10 days, whereas the dual-target stimulation group will be given stimulation of both the left M1 cortex and the right cerebellar hemisphere. The sham stimulation group will be given sham stimulation for 10 days. Tremor will be assessed using both the subjective The Essential Tremor Rating Assessment Scale (TETRAS) and objective accelerometer-based tremor analysis. at baseline (before stimulation), after the first, fifth, tenth days of treatment (D1, 5, 10), 24 h after 10 days of treatment (D10-24 h), and 1, 2, 3, and 4 weeks after stimulation (W1, 2, 3, 4).

Discussion: This is a Phase 2 randomized, controlled, patient-assessor blinded clinical trial. The goal of this study is to investigate the Safety, feasibility and efficiency of TMS for the treatment of ET.

Objective: Endovascular mechanical thrombectomy (EVMT) is widely employed in patients with acute intracranial carotid artery occlusion (AIICAO). This study aimed to predict the outcomes of EVMT following AIICAO by utilizing anatomic classification of the circle of Willis and its relative position to the thrombus.

Methods: In this study, we retrospectively analyzed a cohort of 108 patients with AIICAO who underwent endovascular mechanical thrombectomy (EVMT) at Shaoxing People's Hospital. Based on variations in the circle of Willis, as well as the size and location of the thrombus occluding the middle cerebral artery (MCA), anterior cerebral artery (ACA), and posterior cerebral artery (PCA), we classified AIICAO into four grades using digital subtraction angiography (DSA). EVMT was initiated upon admission, and baseline data including demographic characteristics, vascular risk factors, angiographic features, initial National Institutes of Health Stroke Scale (NIHSS) scores, Alberta Stroke Program Early CT Score (ASPECT), and etiology classification were compared across these four grades. The prognosis and mortality rates at 90 days post-stroke were evaluated for the different grades and within each grade, patients were further categorized into two subtypes based on vascular compensation and occluded vessels.

Results: Significant differences were observed among the four grades of Willis compensation concerning etiologic classification (p = 0.008), postoperative modified treatment in cerebral ischemia (mTICI, p = 0.017), postoperative symptomatic intracranial hemorrhage (sICH, p = 0.007), NIHSS score at admission (p = 0.001), and favorable outcomes at 90 days (modified Rankin Score 0-2) (p = 0.003). The mortality rate at 90 days exhibited a significant difference across the four grades of Willis compensation (p = 0.05). However, prognosis did not reveal any significant differences among the various subtypes within the same grade (p > 0.05).

Conclusion: The assessment of the degree of Willis compensation can be improved by evaluating the integrity of the circle of Willis, as well as the size and location of the clot in cases of isolated internal carotid artery occlusion (iICAo). This approach provides valuable prognostic indicators and important insights for the pre-selection of patients prior to endovascular mechanical thrombectomy (EVMT).

Background: This study aims to investigate how A1 segment asymmetry-also known as A1 dominancy-influences the development of the anterior communicating artery aneurysm (AcomA) as it affects hemodynamic conditions within the circle of Willis (COW). Using time-of-flight magnetic resonance angiography (TOF-MRA), the research introduces a novel approach to assessing shear stress in A1 segments to uncover the hemodynamic factors contributing to AcomA formation.

Method: An observational study was conducted over 6 years at a tertiary university hospital's outpatient clinic. Recruited patients who underwent TOF-MRA imaging were divided into AcomA and non-AcomA groups. MRA images were analyzed using semi-automatic software (VINT, Mediimg, Inc.) to calculate the signal intensity gradient (SIG), which reflects wall shear stress. The comparison metrics included general demographics, anatomical characteristics, and hemodynamic attributes of the COW, mainly focusing on A1 segment asymmetry.

Results: Among the 700 subjects, 106 were categorized into the AcomA group, while 594 were placed in the non-AcomA group. The AcomA group showed a more significant difference in the bilateral A1 diameter (49.0% vs. 20.8%, p < 0.001) and a greater prevalence of unilateral A1 aplasia (32.1% vs. 6.7%, p < 0.001) compared to the non-AcomA group. Increased bilateral A1 asymmetry in the AcomA group corresponded with notable variations in A1 SIG, indicating increased wall shear stress. The occurrence of AcomA is associated with both anatomical factors of the circle of Willis, represented by the bilateral A1 diameter ratio, and hemodynamic factors, represented by the bilateral A1 SIG ratio, suggesting that both factors are almost equally significant.

Conclusion: Our findings suggest that A1 segment asymmetry influences hemodynamic changes within the COW, contributing to AcomA formation. Hemodynamic factors provide an intuitive understanding of how anatomical characteristics within the COW can lead to aneurysm development.

Background: Intracerebral hemorrhage (ICH) is the most lethal and devastating subtype of stroke. Basal ganglia hemorrhage and thalamic hemorrhage are the most common types of ICH, accounting for 50-70% of all ICH cases, leading to disability and death, and it involves the posterior limb of the internal capsule to varying degrees. In this study, we investigated the impact of varying degrees of the involvement of the posterior limb of the internal capsule on the prognosis of patients with basal ganglia and thalamic ICH and assessed whether it improves the predictive accuracy of the max-ICH score, an existing scale for ICH functional outcome.

Methods: This is a multicenter, retrospective, observational study. We graded the involvement of the posterior limb of the internal capsule according to the degree of compression and injury (called iICH, ranging from 0 to 4). An unfavorable outcome was defined as a 90-day modified Rankin Scale (mRS) of > 2. Multivariate logistic regression analysis was used to identify independent risk factors associated with unfavorable prognosis. The discrimination was verified using receiver operating characteristic curve (ROC) analysis, while the calibration was verified by the Hosmer-Lemeshow test.

Results: Of the 305 patients included, 188 from Nanfang Hospital were assigned to the development cohort, and 117 from Heyuan People's Hospital and Huadu District People's Hospital were assigned to the validation cohort. In the development cohort, iICH was identified as an independent factor of a 90-day unfavorable outcome, and the area under the ROC (AUC) was 0.774. When combined with the iICH, the AUC of max-ICH was significantly elevated from 0.816 to 0.866. Comparable results were found in the validation cohort.

Conclusions: Increased involvement of the posterior limb of the internal capsule is associated with a worse outcome in patients with basal ganglia and thalamic ICH.

Background: There is no established treatment for the acute exacerbation of trigeminal neuralgia. We aimed to investigate the efficacy and safety of intravenous fosphenytoin for this disease.

Methods: We conducted a retrospective observational study of data from 41 patients with trigeminal neuralgia who received intravenous fosphenytoin therapy. Fosphenytoin diluted with physiological saline was administered intravenously at a loading dose of 9.8-20.7 mg/kg or at a dose of 7.5-9.5 mg/kg when maintenance therapy was needed. Pain was evaluated using a numerical rating scale (NRS), assessed immediately before administration (baseline) and at 2, 12, and 24 h after administration.

Results: The mean (± standard deviation) NRS score was 9.85 ± 0.69, 0.49 ± 1.47, 1.60 ± 2.19, and 3.46 ± 3.19 at baseline, 2, 12, and 24 h after administration, respectively (p < 0.001). Intravenous fosphenytoin therapy was effective for the acute exacerbation of trigeminal neuralgia regardless of whether it was administered during the perioperative period of microvascular decompression (MVD) or the type of drugs used concomitantly. Fosphenytoin was effective when re-administered (n = 14) or at a maintenance dose (n = 2). The adverse drug reactions observed were mild dizziness in six patients, abnormal auditory perception and thirst in three patients each, and somnolence, decreased SpO₂, and drug eruption in one patient each, all of which were transient.

Conclusions: Intravenous fosphenytoin therapy can immediately eliminate pain during acute exacerbation of trigeminal neuralgia and can be a useful therapeutic drug in emergency response or until elective treatment, such as MVD, is performed.

Introduction: Hemorrhagic transformation (HT) is a severe complication in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) after endovascular treatment (EVT). We hypothesize that asymmetry of the internal cerebral veins (ICVs) on baseline CT angiogram (CTA) may serve as an adjunctive predictor of HT.

Methods: We conducted a study on consecutive AIS-LVO patients from November 2020 to April 2022. These patients had anterior circulation occlusions and were treated with EVT. Asymmetrical ICVs were assessed using CTA and defined as hypodensity (reduced opacification) on the ipsilateral side of occlusion compared to the contralateral side. The primary outcome was HT, defined as hemorrhage within the ischemic territory. This was evaluated using follow-up imaging (CT scan or magnetic resonance imaging) performed 48 h post-EVT. HT was classified into four subtypes based on the European Cooperative Acute Stroke Study-II criteria.

Results: A total of 126 patients were included, with an HT rate of 49.2% (62/126). ICV asymmetry was observed in 54.0% (68/126) of patients. The ICV asymmetry group exhibited a significantly higher risk of parenchymatous hematoma-type HT (33.8% vs. 15.5%, p = 0.019) and symptomatic intracerebral hemorrhage (sICH) (23.5% vs. 5.2%, p = 0.004). In multivariate logistic regression, ICV asymmetry (OR 3.809, 95% CI 1.582-9.171), baseline Alberta Stroke Program Early CT Score (OR 0.771, 95% CI 0.608-0.978), intravenous recombinant tissue plasminogen activator (OR 2.847, 95% CI 1.098-2.7.385), and poor collateral circulation (OR 3.998, 95% CI 1.572-10.169) were identified as independent risk factors of HT.

Conclusion: ICV asymmetry, likely resulting from impaired autoregulation or tissue micro-perfusion hampering cerebral blood flow (CBF), is a novel radiological sign that independently predicts HT. It is associated with a higher risk of sICH in AIS-LVO patients after EVT. Further research is warranted to validate these findings.