Journal of Central Nervous System Disease最新文献

Objective: To report three cases of immediate brainstem hemorrhage following intravenous thrombolysis with tenecteplase (TNK) in patients with minor ischemic stroke, resulting in poor outcomes and death.

Methods: We describe the clinical characteristics, imaging findings, and outcomes of three patients who developed brainstem parenchymal hemorrhage immediately after TNK thrombolysis.

Results: All three patients had minor ischemic stroke (National Institute of Health stroke scale score ≤5) and presented with elevated blood pressure on admission. Blood pressure was lowered to guideline-recommended levels (<180 mmHg) using intravenous antihypertensives before thrombolysis. Despite rapid brain protection measures, including hematoma evacuation or external ventricular drainage in two cases and conservative management in one, all patients died due to brainstem hemorrhage.

Conclusion: These cases suggest that fatal brainstem hemorrhage may occur after TNK thrombolysis in minor stroke. For patients with a history of poorly controlled hypertension, careful risk assessment and aggressive blood pressure management are critical if thrombolysis is considered.

Objectives: Low- and lower-middle-income countries (LMICs) bear a disproportionately high burden of neurosurgical disease while facing severe shortages of trained neurosurgeons and anesthesiologists. Access to advanced technologies such as intraoperative neuromonitoring (IONM), crucial for complex neurosurgical procedures, is virtually nonexistent due to infrastructural, educational, and financial barriers. This study describes the development and implementation of Uganda's first IONM program at Cure Children's Hospital of Uganda (CCHU), using the well validated Exploration, Preparation, Implementation, and Sustainment (EPIS) framework.

Methods: In collaboration with the University of Colorado, a standardized non-traditional training pathway was created, combining remote and in-person instruction in neurophysiology, technical IONM applications, and anesthetic considerations. Over a 3-year period, the program enabled CCHU to safely perform more than 80 complex pediatric neurosurgical cases across 2 years, incorporating modalities such as somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), and electromyography (EMG). Surgical and patient outcomes were not tracked for the purposes of this implementation study.

Results: Between March 2022 and October 2024, 80 surgeries were performed at CCHU that made use of IONM technologies. The vast majority of the surgeries were intracranial and included one awake tumor resection with direct cortical mapping (DCS). A smaller subsect of patients underwent spine surgery for either tumor removal or correction of spinal cord tethering. Due to the difficulty in patient outreach many patients were lost to follow-up, however, efforts are being made to track patients and examine their clinical outcomes.

Conclusion: Despite resource limitations, this initiative demonstrated that IONM can be effectively integrated into LMIC healthcare settings, improving surgical safety and outcomes while contributing to local workforce development. The success of this program underscores the value of international partnerships and implementation science in bridging global neurosurgical disparities and suggests a scalable model for future adoption across similar contexts.

The epidemiology of neuroimmunological disorders in Africa remains poorly understood. Regional variation in diagnostics and provider knowledge has led to challenges in real-world application of diagnostic criteria. We conducted a cross-sectional survey of clinicians practicing in Africa to characterize the current state of clinical diagnostic resources and developed a clinician-driven prioritized action plan. 130 respondents from 24 out of 54 countries in Africa participated (44% national response rate). Most respondents specialized in neurology (n = 86, 66%) and practiced in an urban setting (n = 84, 65%). While all participating countries had access to a neurologist and ophthalmologist, only half had access to an in-country neuroimmunologist. Three-quarters of respondents had access to an MRI within a 25-kilometer radius with most reporting a maximum magnet strength of 1.5 Tesla (n = 46, 61%). The median cost for an MRI brain was 150 USD, and MRI spine was 160 USD. The most urgent action item selected to improve the timely diagnosis of neuroimmunological conditions was subsidizing the cost of MRI followed by increasing availability of MRI. There were notable gaps in availability of specialists and access to MRI to diagnose neuroimmunological conditions in Africa. Urgent action and regional collaborations focused on addressing MRI cost and availability are needed.

Background: Upper limb motor deficits are common after stroke and often persist despite rehabilitation. While clinical assessments emphasize movement quality, they do not capture the underlying neuromuscular impairments, particularly in individuals with mild deficits. This limits the development of individualized treatment approaches.

Objectives: This study aimed to characterize stroke-related changes in muscle recruitment during reaching by separating tonic (gravity-compensating) and phasic (intersegmental dynamics-related) components of EMG activity.

Design: Cross-sectional observational study with a comparative design.

Methods: We recorded surface EMG from 12 upper limb muscles during goal-directed reaching in 8 individuals with unilateral ischemic stroke, 5 age-matched and 9 young individuals. Using principal component analysis, we extracted tonic and phasic components and compared their amplitude, directional tuning, and coactivation patterns across groups. Group differences were evaluated with generalized linear mixed-effects models, regression, and correlation analyses.

Results: Even individuals with mild stroke exhibited abnormal muscle recruitment. Proximal muscles were over-recruited in directions that typically require less activation, indicating altered directional tuning. Phasic activation of distal muscles was significantly reduced and worsened with time post-stroke (R² = 0.52, P = 0.002). Tonic overactivation of proximal muscles was present across all stroke participants. Muscle coactivation patterns were hemisphere-specific: right-hemisphere stroke reduced tonic coactivation in contralateral arms, whereas left-hemisphere stroke increased it. Abnormal phasic coactivation between proximal and distal muscles correlated with impaired intersegmental dynamics compensation (R² = 0.67, P = 0.013). Tonic and phasic impairments were often correlated, suggesting shared disruption of corticospinal and reticulospinal pathways.

Conclusion: These findings reveal distinct yet interacting deficits in tonic and phasic muscle recruitment following stroke, including persistent overactivation of proximal muscles for antigravity support and reduced phasic activation of distal muscles. These results suggest that individualized rehabilitation strategies should address both inefficient gravitational support and impaired intersegmental coordination to reduce post-stroke muscle overactivation and improve movement efficiency.

Retroclival epidural hematoma (EDH) is a rare form of intracranial hemorrhage located between the clivus and the dura mater, predominantly affecting pediatric patients due to the anatomical vulnerability of the craniocervical junction. This case report describes a 4-year-old boy involved in a motorcycle accident who presented with facial trauma and was found to have a retroclival EDH and multiple mandibular fractures. Despite the hematoma measuring 8.7 mm in thickness and 3 cc in volume, the patient remained neurologically intact with a Glasgow Coma Scale of 15. He underwent surgical repair for the mandibular fractures while the retroclival EDH was managed conservatively. The patient recovered fully without neurological deficits at follow-ups extending to 6 months. A comprehensive literature review reveals that retroclival EDH in children is commonly associated with high-energy trauma such as motor vehicle accidents and often results from tectorial membrane stripping injury. While clinical presentations vary, many cases, like the one described, show minimal neurological signs despite the presence of significant hematomas, emphasizing the importance of high clinical suspicion and appropriate neuroimaging. Computed tomography is the initial diagnostic tool, but magnetic resonance imaging is superior for identifying associated ligamentous injuries and differentiating from subdural hematomas. Most pediatric retroclival EDH cases are managed conservatively with excellent outcomes, reserving surgical intervention for cases involving brainstem compression or craniocervical instability. This report reinforces the favorable prognosis of isolated retroclival EDH in neurologically stable pediatric patients and underscores the critical role of imaging and clinical vigilance in trauma assessment.

Background: Emerging evidence has indicated gut dysbiosis as a potential modifiable contributor to the pathogenesis of Parkinson's disease (PD). Fecal microbiota transplantation (FMT), a microbiome-centric model aimed at modulating the intestinal microbial taxa, represents a novel therapeutic approach. However, its safety and efficacy profile in improving PD symptoms remains inadequately researched.

Methods: PubMed, ScienceDirect, and the Cochrane Central Registry were searched to retrieve relevant articles from inception till February 2025. Risk ratios (RR) and Mean differences (MD), along with 95% confidence intervals (CI), were pooled under the random-effect model for dichotomous and continuous outcomes, respectively. The primary outcomes of interest were change in Movement Disorder Society Unified Parkinson's Disease Rating Scale part 1 (MDS-UPDRS 1), change in MDS-UPDRS 2. Secondary endpoints of interest were change in MDS-UPDRS 3 (on medication), change in MDS-UPDRS 3 (off medication), change in MDS-UPDRS 4, change in Irritable Bowel Severity Scoring System (IBS-SSS), change in Montreal Cognitive Assessment (MoCA), change in Parkinson Disease Questionnaire Summary Index (PDQ-39 SI), and GI adverse events. The Cochrane Risk of Bias 2.0 (RoB 2.0) tool was used for the quality assessment of the included randomized controlled trials (RCTs). A Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessment was done for the certainty of evidence.

Results: This systematic review and meta-analysis included 145 patients across 3 RCTs. FMT and placebo were comparable regarding the primary outcomes that include MDS-UPDRS Part I (MD = -0.36; 95% CI:[-2.18,1.45]; P = .70; I² = 33%), Part II (MD = -0.46; 95% CI:[-1.91,0.99]; P = .53; I² = 0%). The secondary outcomes, involving MDS-UPDRS Part III on-medication (MD = 1.41; 95% CI:[-2.14,4.42]; P = .50; I² = 17%), Part III off-medication (MD = 1.26; 95% CI:[-2.27,4.79]; P = .48; I² = 0%), and Part IV (MD = -0.39; 95% CI:[-1.63,0.85]; P = .54; I² = 24%) were also comparable between the two groups. No significant changes were observed in IBS-SSS (MD = -15.91; 95% CI:[-63.17,31.89]; P = .51; I² = 76%), PDQ-39 SI (MD = -2.13, 95% CI:[-5.62,1.36]; P = .23; I² = 0%), and MOCA scores (MD = 0.11; 95% CI:[-1.34,1.57]; P = .88; I² = 68%). However, the FMT group had more frequent adverse gastrointestinal events (RR = 3.32; 95% CI: [1.01,10.87]; P = .05; I² = 39%).

Conclusion: FMT shows no evidence of superiority compared to placebo. Variations in the findings of existing studies suggest that donor fecal composition, host-microbiota interactions, and methodological heterogeneity may determine outcomes. Further RCTs employing tailored microbiota and s

Background: Stroke is one of the leading causes of disability and mortality worldwide, and the 30-day readmission rate is a crucial indicator for assessing the quality of healthcare and patient outcomes. Previous studies have reported a readmission rate of approximately 10%-20%.

Objectives: This study investigated the impact of the COVID-19 pandemic on the readmission rate at 30 days among hospitalized stroke patients.

Methods: This retrospective cohort study was conducted in a 1500-bed medical center in central Taiwan between January 1, 2020, and December 31, 2023. Data, including 5095 hospitalized stroke patients, 505 readmissions within 30 days, and multiple variables that influence hospital readmission at 30 days, including demographics, clinical characteristics, physiological data, and medication use before discharge, were obtained from hospital electronic health records (EHR).

Results: The results revealed a significant decline in 30-day readmission rates between the early (2020∼2021) and latter (2022∼2023) phases of the pandemic, decreasing from 10.71% to 8.97% (P = .039). This reduction may be attributed to improvements in medical strategies, increased adoption of telemedicine, and improved post-discharge care. Generalized linear regression analysis indicated that male patients were at higher risk of readmission than female patients (OR = 1.28, P = .01), while other variables, such as age, BMI, and blood pressure, did not reach statistical significance. Furthermore, common cardiovascular and metabolic medications (antithrombotic agents, lipid-lowering drugs, antihypertensive drugs, and antidiabetic medications) did not significantly affect the risk of readmission (P > .05).

Conclusions: This finding suggests that improvements in medical management during the early pandemic phase may have contributed to a reduced risk of readmission. Furthermore, male patients had a higher risk of readmission, highlighting the need for improved care strategies for this group.

Purpose: This study aimed to evaluate the influence of the triglyceride-glucose index (TyG index) on clinical outcomes and to develop nomogram models for predicting early neurological deterioration (END) and long-term prognosis in acute ischemic stroke (AIS) patients following intravenous thrombolytic (IVT) therapy.

Methods: We conducted a multi-center retrospective cohort study involving 333 AIS patients treated with IVT. The short-term and long-term outcomes were defined as the occurrence of END and 90-day prognosis. Multivariate logistic regression was used to develop nomogram models for forecasting these clinical outcomes.

Results: Patients in the high-TyG group exhibited significantly higher risks of END (P = 0.0010) and poor 90-day outcomes (P = 0.0012). Independent risk factors for END included a lower baseline NIHSS score, delayed door-to-needle time (DNT), reduced ASPECTS score, elevated TyG index, higher potassium (K+) levels, and incomplete Willis artery. Additionally, a higher initial NIHSS, increased TyG levels, presence of END, and a history of hypertension were predictors of poor prognosis. Based on the identified risk factors, two nomogram models yielded AUC values of 0.746 and 0.849 for predicting END and poor prognosis, respectively. NIHSS scores, TyG index, and admission glucose levels (Glu) emerged as prognostic indicators across all patients, while higher mean platelet volume (MPV) and history of stroke were identified as novel risk factors for poor prognosis in NO-END group.

Conclusion: A higher TyG index correlates with poor clinical outcomes in AIS patients post-IVT. The nomograms combining the TyG index with various factors enhanced risk prediction for END and poor prognosis.

Background: Epidural spinal cord stimulation (EES) is a promising intervention for motor rehabilitation after spinal cord injury (SCI), but the extent and trajectory of motor recovery remain unclear.

Objective: This phase II trial evaluates the acquisition of voluntary movements in paraplegic patients (ASIA A or B) following SCI, assessed by the Fugl-Meyer Lower Extremity (FMA-LE) score and electromyography (EMG).

Methods: This interim analysis includes five patients implanted with EES and followed for 12 months. The primary outcome was motor recovery, measured by FMA-LE and EMG. Secondary outcomes included balance (Berg Balance Scale), spasticity (Modified Ashworth Scale), pain, autonomic functions, mood, quality of life (WHO-QOL), and safety. Adverse events were monitored.

Results: The FMA-LE score improved from 36 ± 9 (SD) to 55 ± 2 at 3 months (P < 0.05), 59 ± 2 at 6 months (P < 0.05), and 64 ± 4 at 12 months (P < 0.05). EMG confirmed increased voluntary activation. Balance and spasticity improved, while pain and autonomic functions remained unchanged. Motor gains plateaued after 5 months, reaching 68% above baseline. No serious adverse events occurred, though minor complications included transient nociceptive pain and a self-resolving pressure ulcer.

Conclusions: These findings support the role of EES in facilitating early motor recovery in SCI patients, consistent with prior studies. However, the plateau effect suggests a limit to long-term gains. Future research should explore strategies to sustain improvements, including regenerative therapies or optimized neuromodulation protocols.Trial registration number: NCT06847295.