The neurological examination, developed and tested since the 1800s has provided physicians with a vital tool to rapidly assess and provide clues to many of the pathological processes lurking inside the brain and spina...The neurological examination, developed and tested since the 1800s has provided physicians with a vital tool to rapidly assess and provide clues to many of the pathological processes lurking inside the brain and spinal cord. With the advent of magnetic resonance imaging, physicians are able to visualize the precise location of the abscess before surgical intervention. In this case report, we present a 51-year-old male with an epidural abscess with multifocal compressive myelopathy, resulting in a complicated neurological examination, making localization a diagnostic challenge. With this case, we would like to stress that complicated multifocal lesions of the cord may present with a large variation in examination findings. This patient’s neurological exam was complicated secondary to a ventrally as well as dorsally located epidural abscess with superimposed spinal shock sequelae. We would like to highlight the importance of a thorough history and the neurological examination but also mention some of its limitations. It is crucial to use clinical judgement to navigate the patient’s history, presentation, and examination to accurately diagnose and treat, particularly so in cases involving compressive myelopathies of the spinal cord.展开更多
There is increasing evidence that infants with mild neonatal encephalopathy(NE) have significant risks of mortality, brain injury and adverse neurodevelopmental outcomes. In the era of therapeutic hypothermia, infants...There is increasing evidence that infants with mild neonatal encephalopathy(NE) have significant risks of mortality, brain injury and adverse neurodevelopmental outcomes. In the era of therapeutic hypothermia, infants need to be diagnosed within 6 hours of birth, corresponding with the window of opportunity for treatment of moderate to severe NE, compared to the retrospective grading over 2 to 3 days, typically with imaging and formal electroencephalographic assessment in the pre-hypothermia era. This shift in diagnosis may have increased the apparent prevalence of brain damage and poor neurological outcomes seen in infants with mild NE in the era of hypothermia. Abnormal short term outcomes observed in infants with mild NE include seizures, abnormal neurologic examination at discharge, abnormal brain magnetic resonance imaging and difficulty feeding. At 2 to 3 years of age, mild NE has been associated with an increased risk of autism, language and cognitive deficits. There are no approved treatment strategies for these infants as they were not included in the initial randomized controlled trials for therapeutic hypothermia. However, there is already therapeutic creep, with many centers treating infants with mild NE despite the limited evidence for its safety and efficacy. The optimal duration of treatment and therapeutic window of opportunity for effective treatment need to be specifically established for mild NE as the evolution of injury is likely to be slower, based on preclinical data. Randomized controlled trials of therapeutic hypothermia for infants with mild NE are urgently required to establish the safety and efficacy of treatment. This review will examine the evidence for adverse outcomes after mild NE and dissect some of the challenges in developing therapeutic strategies for mild NE, before analyzing the evidence for therapeutic hypothermia and other strategies for treatment of these infants.展开更多
INTRODUCTIONThe prognosis of patients who suffer from coma after cardiopulmonary resuscitation （CPR） may be poor （defined as cerebral performance categories scores from 3 to 5） Thus, an accurate prediction of thei...INTRODUCTIONThe prognosis of patients who suffer from coma after cardiopulmonary resuscitation （CPR） may be poor （defined as cerebral performance categories scores from 3 to 5） Thus, an accurate prediction of their neurological outcomes is an essential component of post-cardiac arrest evaluation, especially for decisions to limit or withdraw life-sustaining care. Since the 1960s, a series of domestic and foreign studies began to focus on the evaluation of coma patients after CPR, and considerable progress has been achieved in this field.展开更多
目的:探讨神经系统体格检查各指标和血清神经元特异性烯醇化酶(neuron specific enolase,NSE)浓度对心脏骤停患者神经不良预后的预测价值。方法:回顾性研究院外心脏骤停患者,根据发病30 d的脑功能表现(cerebral performance category,C...目的:探讨神经系统体格检查各指标和血清神经元特异性烯醇化酶(neuron specific enolase,NSE)浓度对心脏骤停患者神经不良预后的预测价值。方法:回顾性研究院外心脏骤停患者,根据发病30 d的脑功能表现(cerebral performance category,CPC)分级分为良好组(CPC≤2级)和不良组(CPC≥3级)。血清NSE浓度和发病后3 d对光反射,根据格拉斯哥昏迷评分(Glasgow coma scale,GCS)测量的睁眼评分(eGCS)、肢体运动评分(mGCS)和两者之和(emGCS),计算3 d内eGCS改变(ΔeGCS)、mGCS改变(ΔmGCS)和emGCS改变情况(ΔemGCS)。使用重复测量评估相关性,利用Logistic回归分析寻找单因素和多因素预测指标。结果:不良组的NSE显著高于良好组(P<0.01)。3 d内ΔmGCS和ΔemGCS良好组显著高于不良组(P<0.05)。重复测量方差分析示eGCS、mGCS和emGCS与CPC分级呈负相关(P<0.001)。广义线性混合效应模型分析示不存在对光反射与心肺复苏的不良预后相关(P=0.002)。3 d e GCS、mGCS和emGCS,第2、3天对光反射,ΔmGCS、ΔemGCS和NSE为心脏骤停神经不良预后的单因素预测指标(P<0.05)。男性和第3天的mGCS低为心脏骤停患者神经不良预后的多因素预测指标(P<0.05)。结论:联合第3天的mGCS和性别为男性可预测心脏骤停患者不良神经系统预后。展开更多
文摘The neurological examination, developed and tested since the 1800s has provided physicians with a vital tool to rapidly assess and provide clues to many of the pathological processes lurking inside the brain and spinal cord. With the advent of magnetic resonance imaging, physicians are able to visualize the precise location of the abscess before surgical intervention. In this case report, we present a 51-year-old male with an epidural abscess with multifocal compressive myelopathy, resulting in a complicated neurological examination, making localization a diagnostic challenge. With this case, we would like to stress that complicated multifocal lesions of the cord may present with a large variation in examination findings. This patient’s neurological exam was complicated secondary to a ventrally as well as dorsally located epidural abscess with superimposed spinal shock sequelae. We would like to highlight the importance of a thorough history and the neurological examination but also mention some of its limitations. It is crucial to use clinical judgement to navigate the patient’s history, presentation, and examination to accurately diagnose and treat, particularly so in cases involving compressive myelopathies of the spinal cord.
基金supported by The Health Research Council of New Zealand(18/225,17/601,and 16/003)。
文摘There is increasing evidence that infants with mild neonatal encephalopathy(NE) have significant risks of mortality, brain injury and adverse neurodevelopmental outcomes. In the era of therapeutic hypothermia, infants need to be diagnosed within 6 hours of birth, corresponding with the window of opportunity for treatment of moderate to severe NE, compared to the retrospective grading over 2 to 3 days, typically with imaging and formal electroencephalographic assessment in the pre-hypothermia era. This shift in diagnosis may have increased the apparent prevalence of brain damage and poor neurological outcomes seen in infants with mild NE in the era of hypothermia. Abnormal short term outcomes observed in infants with mild NE include seizures, abnormal neurologic examination at discharge, abnormal brain magnetic resonance imaging and difficulty feeding. At 2 to 3 years of age, mild NE has been associated with an increased risk of autism, language and cognitive deficits. There are no approved treatment strategies for these infants as they were not included in the initial randomized controlled trials for therapeutic hypothermia. However, there is already therapeutic creep, with many centers treating infants with mild NE despite the limited evidence for its safety and efficacy. The optimal duration of treatment and therapeutic window of opportunity for effective treatment need to be specifically established for mild NE as the evolution of injury is likely to be slower, based on preclinical data. Randomized controlled trials of therapeutic hypothermia for infants with mild NE are urgently required to establish the safety and efficacy of treatment. This review will examine the evidence for adverse outcomes after mild NE and dissect some of the challenges in developing therapeutic strategies for mild NE, before analyzing the evidence for therapeutic hypothermia and other strategies for treatment of these infants.
文摘INTRODUCTIONThe prognosis of patients who suffer from coma after cardiopulmonary resuscitation （CPR） may be poor （defined as cerebral performance categories scores from 3 to 5） Thus, an accurate prediction of their neurological outcomes is an essential component of post-cardiac arrest evaluation, especially for decisions to limit or withdraw life-sustaining care. Since the 1960s, a series of domestic and foreign studies began to focus on the evaluation of coma patients after CPR, and considerable progress has been achieved in this field.
文摘目的:探讨神经系统体格检查各指标和血清神经元特异性烯醇化酶(neuron specific enolase,NSE)浓度对心脏骤停患者神经不良预后的预测价值。方法:回顾性研究院外心脏骤停患者,根据发病30 d的脑功能表现(cerebral performance category,CPC)分级分为良好组(CPC≤2级)和不良组(CPC≥3级)。血清NSE浓度和发病后3 d对光反射,根据格拉斯哥昏迷评分(Glasgow coma scale,GCS)测量的睁眼评分(eGCS)、肢体运动评分(mGCS)和两者之和(emGCS),计算3 d内eGCS改变(ΔeGCS)、mGCS改变(ΔmGCS)和emGCS改变情况(ΔemGCS)。使用重复测量评估相关性,利用Logistic回归分析寻找单因素和多因素预测指标。结果:不良组的NSE显著高于良好组(P<0.01)。3 d内ΔmGCS和ΔemGCS良好组显著高于不良组(P<0.05)。重复测量方差分析示eGCS、mGCS和emGCS与CPC分级呈负相关(P<0.001)。广义线性混合效应模型分析示不存在对光反射与心肺复苏的不良预后相关(P=0.002)。3 d e GCS、mGCS和emGCS,第2、3天对光反射,ΔmGCS、ΔemGCS和NSE为心脏骤停神经不良预后的单因素预测指标(P<0.05)。男性和第3天的mGCS低为心脏骤停患者神经不良预后的多因素预测指标(P<0.05)。结论:联合第3天的mGCS和性别为男性可预测心脏骤停患者不良神经系统预后。
