JNS.jpgThe June issue of the Journal of the Neurological Sciences Vol 413 is now available online.


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Issue highlights

Spinal arteriovenous fistula's often misdiagnosed as myelitis; can we stem the flow?

Spinal arteriovenous fistulas (SAVF) are abnormal connections between spinal arteries and veins in the absence of bridging capillary network that may lead to severe neurological disability. SAVF are commonly classified according to their anatomical location (epidural, dural, and intradural [intramedullary or perimedullary]) and blood flow pattern based on the duration of the arterial phase on angiography (high-flow vs low-flow). This latter distinction is of particular interest for neurologists as it highlights important clinical and pathophysiological differences in patients with SAVF.

High-flow fistulas are characterized by elevated intraluminal pressure and typically result in acute neurosurgical emergencies due to spontaneous bleeding, secondary high-output cardiac failure, or spinal cord infarction from arterial steal. On the contrary, low-flow fistulas typically manifest as a slowly progressive myelopathy secondary to prolonged venous hypertension, spinal cord congestion, and consequent ischemia, which is more likely to come to the attention of neurologists rather than neurosurgeons].

Blood pressure variability and outcome after acute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is life threatening neurologic event that results in significant rate of morbidity and mortality. Unfortunately, several randomized clinical trials aiming at limiting the hematoma expansion (HE) in the acute phase of ICH have not shown significant effects in improving the functional outcomes.

Blood pressure variability (BPV) is common following ICH. High BPs have been associated with increased risk of bleeding and HE. Conversely, recurrent sudden decrease in BP promote perihematomal ischemia. However, it is still not clear weather BPV causes adverse prognosis following ICH or large ICHs cause fluctuations in BP.

In the current review, we will discuss the mechanistic pathophysiology of BPV and the evidence regarding the role of BPV on the ICH outcomes.

Purulent infectious myositis (formerly tropical pyomyositis)

Purulent infectious myositis (PIM), formerly known as tropical pyomyositis, is a pyogenic infection of skeletal muscles. Staphylococcus aureus, a normal human skin inhabitant, is the main pathogen involved, but multiple other microorganisms have been implicated.

Although usually a progressive febrile disease with pain in the affected muscle(s), severe, life-threatening forms have been described, especially in immunosuppressed patients and children. PIM may elude early diagnosis given the lack of overlying skin changes. Hence, high index of suspicion followed by imaging modalities (ultrasonography when superficial and computed tomography or magnetic resonance imaging with contrast when deep) help confirm the diagnosis.

Treatment requires combination of percutaneous or open surgical drainage along with antimicrobial therapy guided by culture results. The rising incidence of cases due to methicillin-resistant Staphylococcus aureus (MRSA) strains, makes the inclusion of vancomycin be recommended.

This paper reviews PIM highlighting its global distribution, causative agents, predisposing factors, management, and potential complications.

The impact of multiple sclerosis relapses on worsening over the long term; insights in the treatment era

Relapses of multiple sclerosis (MS) are the clinical manifestations of inflammatory events involving eloquent anatomical structures within the central nervous system. Relapses are associated with worsening disability of MS patients in both early and later disease, even after progressive features are seen.

The impact of relapses on the long-term course of the disease is now being realized as a generation of treated patients is now elderly. New MRI brain lesions can be viewed as a radiologic manifestation of acute inflammation and are associated with similar prognostic value.

The complex relationship between clinical relapse activity and later slow progressive worsening remains incompletely understood, however, there is increasing biological plausibility for a causative association between relapse activity and lifelong disability.