Clinical Neuroscience

[The complex intensive care and rehabilitation of a quadriplegic patient using a diaphragm pacemaker]

FODOR Gábor1, GARTNER Béla1, KECSKÉS Gabriella1

JULY 30, 2020

Clinical Neuroscience - 2020;73(07-08)

DOI: https://doi.org/10.18071/isz.73.0269

[A 21 year female polytraumatized patient was admitted to our unit after a serious motorbike accident. We carried out CT imaging, which confirmed the fracture of the C-II vertebra and compression of spinal cord. Futhermore, the diagnostic investigations detected the compound and comminuted fracture of the left humerus and femur; the sacrum and the pubic bones were broken as well. After the stabilization of the cervical vertebra, a tracheotomy and the fixation of her limbs were performed. She spent 1.5 years in our unit. Meanwhile we tried to fix all the medical problems related to tetraplegia and respiratory insufficiency. As part of this process she underwent an electrophysiological examination in Uppsala (Sweden) and a diaphragm pacemaker was implanted. Our main goal was to reach the fully available quality of life. It is worth making this case familiar in a wider range of public as it could be an excellent example for the close collaboration of medical and non-medical fields.]

AFFILIATIONS

  1. Petz Aladár Megyei Oktató Kórház, Központi Aneszteziológia és Intenzív Terápiás Osztály, Gyôr

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Clinical Neuroscience

Extraskeletal, intradural, non-metastatic Ewing’s sarcoma. Case report

OTTÓFFY Gábor, KOMÁROMY Hedvig

Intracranial localization of Ewing’s sarcoma is considerably very rare. Herein, we present clinical and neuroimaging findings regarding a 4-year-old boy with intracranial Ewing’s sarcoma. He was born prematurely, suffered intraventricular haemorrhage, posthaemorrhagic hydrocephalus developed, and a ventriculoperitoneal shunt was inserted in the newborn period. The patient endured re­gular follow ups, no signs of shunt malfunction nor increased intracranial pressure were observed. The last neuroima­ging examination was performed at 8 months of age. Upon reaching the age of 4 years, repeated vomiting and focal seizures began, and symptoms of increased intracranial pressure were detected. A brain MRI depicted a left frontoparietal space-occupying lesion infiltrating the superior sagittal sinus. The patient underwent a craniotomy resulting in the total excision of the tumour. The histological examination of the tissue revealed a small round blue cell tumour. The diagnosis was confirmed by the detection of EWSR1 gene translocation with FISH (fluorescent in situ hybridization). No additional metastases were detected during the staging examinations. The patient was treated in accordance to the EuroEwing 99 protocol. Today, ten years onward, the patient is tumour and seizure free and has a reasonably high quality of life.

Clinical Neuroscience

Life threatening rare lymphomas presenting as longitudinally extensive transverse myelitis: a diagnostic challenge

TOLVAJ Balázs, HAHN Katalin, NAGY Zsuzsanna, VADVÁRI Árpád, CSOMOR Judit, GELPI Ellen, ILLÉS Zsolt, GARZULY Ferenc

Background and aims – Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports – Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion – Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.

Clinical Neuroscience

[Decisional collisions between evidence and experience based medicine in care of people with epilepsy]

RAJNA Péter

[Background – Based on the literature and his long-term clinical practice the author stresses the main collisions of evidence and experience based medicine in the care of people with epilepsy. Purpose – To see, what are the professional decisions of high responsibility in the epilepsy-care, in whose the relevant clinical research is still lacking or does not give a satisfactory basis. Methods – Following the structure of the Hungarian Guideline the author points the critical situations and decisions. He explains also the causes of the dilemmas: the lack or uncertainty of evidences or the difficulty of scientific investigation of the situation. Results – There are some priorities of experience based medicine in the following areas: definition of epilepsy, classification of seizures, etiology – including genetic background –, role of precipitating and provoking factors. These are able to influence the complex diagnosis. In the pharmacotherapy the choice of the first drug and the optimal algorithm as well as the tasks during the care are also depends on personal experiences sometimes contradictory to the official recommendations. Same can occur in the choice of the non-pharmacological treatments and rehabilitation. Discussion and conclusion – Personal professional experiences (and interests of patients) must be obligatory accessories of evidence based attitude, but for achieving the optimal results, in some situations they replace the official recommendations. Therefore it is very important that the problematic patients do meet experts having necessary experiences and also professional responsibility to help in these decisions. ]

Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

[Objective measurement of manual dexterity of Parkinson patients operated with DBS]

SZÁNTÓ Ildikó, SÁNDOR Balázs, KATONA Krisztián, NAGY Máté, JUHÁSZ Annamária, BALÁS István

[The evaluation of hand dexterity is an important marker for the success of DBS (deep brain stimulation) operation in patients with Parkinson’s disease. In this study we applied a simple, semiquantitative optical dental plaque staining technique for the evaluation of the hand dexterity. Ten patient with Parkinson’s disease were involved in the study. After dental students aided tooth brushing, bacterial dental deposits (plaque) were stained then photographed, and quantified under standard conditions before and after DBS surgery. Our results showed a significant decrease in dental plaque deposits after DBS operation. This simple technique seems to be a routinely applicable marker for the evaluation of the hand dexterity. Our future plans is repeating the previous experiement on a higher number of cases.]

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The effects of the level of spinal cord injury on life satisfaction and disability

GULSAH Karatas, NESLIHAN Metli, ELIF Yalcin, RAMAZAN Gündüz, FATIH Karatas, MÜFIT Akyuz

Introduction - Spinal Cord Injury (SCI) may often lead to significant disability in affected individuals and reduce life satisfaction. Herein we aimed to investigate the effects of the level of injury on disability and life satisfaction as well as the relation between life satisfaction and disability. Methods - Patients with at least one-year history of SCI were included. Demographic-clinical data of patients were recorded. The Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF) was used for quantifying the degree of patients’ disability. Life satisfaction was assessed by the Satisfaction with Life Scale (SWLS). Results - Of the 76 patients, 21 (27.6%) were tetraplegic and 55 (72.4%) were paraplegic. SWLS was found to be similar in tetraplegic vs. paraplegic patients (P=0.59), whereas CHART parameters such as physical independence, mobility, occupation, and total CHART value were significantly higher in paraplegic patients (P=0.04, P=0.04, P=0.001 and P=0.01, respectively). Social integration was found similarly high in both groups. There was a positive correlation between elapsed time after the injury and CHART physical independence, occupation and the level of economic sufficiency (P<0.01, P<0.01, P=0.01). Excluding the economic sufficiency (P=0.02), there was not any other association between the rest of CHART parameters and SWLS. Conclusions - According to our findings, although the level of injury seems to be influential on disability, it seems to have no significant effect on life satisfaction. Since the only thing that positively affects life satisfaction is economic sufficiency, more emphasis should be placed on regulations that increase the return to work in patients.

LAM KID

[Current treatment and rehabilitation of the hip fractures - The role of orthopedic surgeons in the investigation and treatment of osteoporosis]

FLÓRIS István, KRICSFALUSY Mihály, UDVARDY Csaba, SOMOGYI Péter

[The treatment of proximal femoral fractures is one of the most common surgical indications in traumatology, on the other hand, it requires a significant proportion of health expenditures. The structure of our society is going to shift toward the older generation in the next decades, which increases the importance of the above factors. New implants and surgical techniques appear in order to make the treatment more effective, thus allowing the patient’s early rehabilitation. In this article, we summarise the diagnosis and treatment of hip fractures, the most serious consequence of osteoporosis, and describe the results of rehabilitation. We describe the role and possibilities of orthopedic surgeons in the investigation and treatment of patients with osteoporotic hip fractures as well as possibilities of tertiary prevention and suggest possibilities of cooperation among the co-professions dealing with osteoporosis in the treatment of this patient group.]

Lege Artis Medicinae

[REHABILITATION AFTER ACUTE CORONARY SYNDROME]

SÁNDORI Klára

[Changes that have occurred in the treatment of acute coronary syndrome have also had an impact on rehabilitation. Unfortunately, current international and national professional guidelines barely take this into account. At present, most patients after acute coronary intervention are certainly not directed to take part in rehabilitation programmes. Thus those very patients miss these programmes who would gain the most benefit from a multi-disciplinary approach to rehabilitation. It would be necessary to develop standard guidelines for the selection of patients. The outcome of the interventions is highly affected by the patients' personality and psychosocial status. It has become obvious that in addition to physical exercise, which is useful but not a cure-all, psychosocial intervention is a key component of successful rehabilitation. This, however, is possible only by increasing the number of rehabilitation professionals and also by the fundamental improvement of financing.]

Clinical Neuroscience

[IMPROVING FUNCTIONAL ELECTRICAL STIMULATION DRIVEN CYCLING BY PROPER SYNCHRONIZATION OF THE MUSCLES]

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[Our aim is to define optimal stimulation patterns for controlling lower limb movements of spinal cord injured patients. Here we report on a study about cycling movements of healthy subjects under regular conditions and spinal cord injured patients whose cycling movement was generated by functional electrical stimulation. The stimulation pattern required for coordinated activities of lower limb muscles of spinal cord injured patients was improved by using the observations what we gained from measuring and analyzing cycling movements of 42 young healthy subjects. Kinematical parameters (joint angles) and muscle activities (EMG) were recorded simultaneously by an ultrasound based movement analyzing system. We replaced the cycling program of the commercially available stimulator with a new one that we developed on the basis of the measured healthy cycling movements. We present that our new stimulation patterns provided a great increase in the performance of our spinal cord injured patients.]

Lege Artis Medicinae

[What does the „whole”-ness of patients with diabetes mellitus mean?]

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[Diabetes mellitus is a chronic, progressive disease, characterized by elevated levels of blood glucose, can lead to many complications and can increase the overall risk of early disability and dying prematurely. The newest guidelines on management of patients with diabetes mellitus give a full description of diagnostic criteria, prevention, lifestyle and pharmacological treatment, complications, age-related characteristics. However, in everyday care of patients with diabetes mellitus little attention is paid to severity of anatomical and functional impairment related to disease, how and in what extent those limit everyday activities, restricts filling the social role, the importance of interrelationship of a human being and environment, to personal factors. The aims of this publication is: to present how diabetes mellitus influences the entirety, the “whole”-ness of a human; to show tools of objective estimation of impairments and changes of functionality; to call attention to importance of development of residual abilities, of shaping supportive environment, of assessment of needs, of positive influences of personal characteristics; to demonstrate how all these measures improve quality of life and compliance of patient with diabetes mellitus. The holistic approach of “human’s whole-ness” can contribute to success of preventive, curative and rehabilitative measures in patients with diabetes mellitus.]