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Journal of Stroke and Cerebrovascular... May 2021Body lateropulsion (BLP) is seen in neurological lesions involving the pathways responsible for body position and verticality. We report a case of isolated body...
INTRODUCTION
Body lateropulsion (BLP) is seen in neurological lesions involving the pathways responsible for body position and verticality. We report a case of isolated body lateropulsion (iBLP) as the presentation of lateral medullary infarction and conducted a systematic literature review.
METHODS
MEDLINE and EMBASE databases were searched up to December 3, 2020.
INCLUSION CRITERIA
age ≥ 18, presence of BLP, confirmed stroke on imaging.
EXCLUSION CRITERIA
age < 18, qualitative reviews, studies with inadequate patient data. Statistical analysis was performed using IBM® SPSS® Statistics 20.
RESULTS
A 64-year-old man presented with acute-onset iBLP. Brain MRI demonstrated acute infarction in the right caudolateral medulla. His symptoms progressed with ipsilateral Horner syndrome over the next 24 hours and contralateral hemisensory loss 10 days later. Repeat MRI showed an increase in infarct size. BLP resolved partially at discharge. Systematic review: 418 abstracts were screened; 59 studies were selected reporting 103 patients. Thirty-three patients had iBLP (32%). BLP was ipsilateral to stroke in 70 (68%) and contralateral in 32 (32%). The most common stroke locations were medulla (n = 63, 59%), pons (n = 16, 15%), and cerebellum (n = 16, 15%). Four strokes were cortical, 3 frontal and 1 temporoparietal (3%). The most common etiology was large-artery atherosclerosis (LAA) in 20 patients (32%), followed by small-vessel occlusion in 12 (19%). Seventeen (27%) had large-vessel occlusion (LVO), 12 involving the vertebral artery. Sixty (98%) had some degree of resolution of BLP; complete in 41 (70%). Median time-to-resolution was 14 days (IQR 10-21). There was no relationship between time-to-resolution and age, sex, side of BLP or side of stroke.
CONCLUSION
BLP was commonly seen with medullary infarction and was the isolated finding in one-third. LAA and LVO were the most common etiologies. Recovery of BLP was early and complete in most cases.
Topics: Brain Stem Infarctions; Diffusion Magnetic Resonance Imaging; Horner Syndrome; Humans; Male; Middle Aged; Postural Balance; Sensation Disorders
PubMed: 33652344
DOI: 10.1016/j.jstrokecerebrovasdis.2021.105680 -
International Journal of Obstetric... Aug 2018Horner's syndrome is a rarely reported complication of neuraxial blockade. In obstetric practice, the neurological signs of Horner's syndrome may cause anxiety amongst... (Review)
Review
Horner's syndrome is a rarely reported complication of neuraxial blockade. In obstetric practice, the neurological signs of Horner's syndrome may cause anxiety amongst patients and healthcare staff, but more importantly may herald the onset of maternal hypotension. Medline, CINAHL, and EMBASE databases were searched to identify cases of Horner's syndrome following obstetric neuraxial blockade. Anaesthetic technique, clinical features, anaesthetic management of the Horner's syndrome and time to resolution were assessed. Seventy-eight case reports of Horner's syndrome following obstetric neuraxial blockade were identified. Nine cases also had trigeminal nerve palsy and one case had hypoglossal nerve palsy. Amongst the 78 cases, 74% developed Horner's syndrome within one hour of a local anaesthetic bolus. The median time for resolution of Horner's syndrome was two hours, though one case was permanent. One case of Horner's syndrome was found to be due to an internal carotid artery dissection. Some cases of Horner's syndrome resolved spontaneously despite ongoing administration of epidural local anaesthetic. Hypotension was reported in 13%. Horner's syndrome is usually a benign phenomenon, the consequence of high cephalad spread of local anaesthetic, that resolves spontaneously within a few hours. Patients with a persistent Horner's syndrome, or one associated with atypical features such as neck pain, should undergo a diagnostic workup including magnetic resonance angiography of the neck. The dermatomal level of neuraxial blockade, maternal and fetal well-being should be taken into account when making decisions regarding neuraxial blockade. The presence of Horner's syndrome alone should not lead to discontinuation of neuraxial blockade.
Topics: Adult; Anesthesia, Obstetrical; Eye; Face; Female; Horner Syndrome; Humans; Nerve Block; Pregnancy
PubMed: 29657082
DOI: 10.1016/j.ijoa.2018.03.005 -
Archives of Disease in Childhood Oct 2019Horner's syndrome (HS) is characterised by a triad of ocular miosis, ptosis and anhidrosis. HS may be a subtle sign of occult pathology in otherwise asymptomatic...
OBJECTIVE
Horner's syndrome (HS) is characterised by a triad of ocular miosis, ptosis and anhidrosis. HS may be a subtle sign of occult pathology in otherwise asymptomatic children, neuroblastoma (NBL) being the the most common associated malignant tumour. Despite such knowledge, the incidence of underlying malignancy in children with HS remains unclear and robust evidence to guide best clinical practice is sparse. We performed a systematic review of the literature with the aim of identifying the incidence of NBL in children with HS of unknown aetiology, and establishing if screening for NBL should be routinely performed in this patient population.
METHODS
Systematic review of the literature (PubMed and Ovid/Medline database, 1961-2018).
RESULTS
The initial search identified 334 manuscripts, of which 8 studies were included in the final analysis. All reports were single-centre retrospective studies without control groups and included a total of 152 patients (age range 0-20 years). All studies investigated patients with HS but without previously established diagnosis. In the studies included, 17 out of a total of 152 patients were diagnosed with a space-occupying lesion. 12 out of the 152 patients were subsequently detected with NBL.
CONCLUSION
HS in children may be the first sign of occult malignancy. We report the first systematic review that comprehensively investigates the incidence of malignancy in this unique patient cohort. We show that HS of unknown aetiology in children warrants further investigation(s) to exclude an underlying space-occupying lesion. This should include cross-sectional imaging of the brain, neck and thorax, plus urinary catecholamines for prompt diagnosis and treatment.
Topics: Algorithms; Brain Neoplasms; Catecholamines; Child; Horner Syndrome; Humans; Neoplasms; Neuroblastoma
PubMed: 31186293
DOI: 10.1136/archdischild-2019-317007 -
European Journal of Anaesthesiology Jun 2019Interscalene brachial plexus blockade is the most common regional anaesthesia technique for alleviating pain after shoulder surgery, but complications occur, including... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Interscalene brachial plexus blockade is the most common regional anaesthesia technique for alleviating pain after shoulder surgery, but complications occur, including ipsilateral hemidiaphragmatic paresis, Horner's syndrome and hoarseness. The supraclavicular approach might be an effective alternative with fewer adverse effects.
OBJECTIVES
The aim of this study was to determine whether there is a difference in postoperative pain scores and morphine equivalents between interscalene and supraclavicular brachial plexus blocks. Secondary endpoints were serious adverse events.
DESIGN
A systematic review and meta-analysis of randomised controlled trials.
DATA SOURCES
A comprehensive literature search of Embase, CENTRAL, MEDLINE and Web of Science was performed from the earliest record to December 2018.
ELIGIBILITY CRITERIA
Prospective randomised controlled trials that compare interscalene and supraclavicular brachial plexus blocks in patients undergoing shoulder surgery were eligible for inclusion. Only studies that reported their methods transparently and comprehensibly were included. Conference abstracts or meeting abstracts were not excluded a priori. Risk of bias was assessed using Cochrane methodology.
RESULTS
Twelve studies were eligible for meta-analysis. The supraclavicular approach showed overall comparable 24-h pain scores (mean difference -0.34; 95% CI -0.75 to 0.07, P = 0.11) and comparable morphine equivalent consumption (mean difference 1.84 mg per 24 h; 95% CI -0.00 to 3.69, P = 0.05). Secondary endpoint analysis revealed a significantly lower rate of hemidiaphragmatic paresis (risk ratio 0.56; 95% CI 0.39 to 0.82, P = 0.003) and Horner's syndrome (risk ratio 0.29; 95% CI 0.19 to 0.44, P < 0.00001) for the supraclavicular approach. There was no significant difference in hoarseness (risk ratio 0.73; 95% CI 0.48 to 1.13, P = 0.16).
CONCLUSION
After 24 postoperative hours, pain scores and consumption of morphine equivalents were comparable. Adverse effects were less common with the supraclavicular approach. The supraclavicular approach might be an efficient alternative to the interscalene approach for shoulder surgery. However, the available evidence is inadequate and prevents a firm conclusion.
Topics: Anesthetics, Local; Brachial Plexus Block; Hoarseness; Horner Syndrome; Humans; Orthopedic Procedures; Pain Measurement; Pain, Postoperative; Pneumothorax; Randomized Controlled Trials as Topic; Respiratory Paralysis; Shoulder Joint
PubMed: 31045699
DOI: 10.1097/EJA.0000000000000988 -
The Cochrane Database of Systematic... Feb 2021Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need for general anaesthesia.
OBJECTIVES
To assess the effects of paravertebral anaesthesia with or without sedation compared to general anaesthesia in women undergoing breast cancer surgery, with important outcomes of quality of recovery, postoperative pain at rest, and mortality.
SEARCH METHODS
On 6 April 2020, we searched the Specialised Register of the Cochrane Breast Cancer Group (CBCG); CENTRAL (latest issue), in the Cochrane Library; MEDLINE (via OvidSP); Embase (via OvidSP); the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal; and ClinicalTrials.gov for all prospectively registered and ongoing trials.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) conducted in adult women undergoing breast cancer surgery in which paravertebral anaesthesia with or without sedation was compared to general anaesthesia. We did not include studies in which paravertebral anaesthesia was given as an adjunct to general anaesthesia and then this was compared to use of general anaesthesia.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted details of trial methods and outcome data from eligible trials. When data could be pooled, analyses were performed on an intention-to-treat basis, and the random-effects model was used if there was heterogeneity. When data could not be pooled, the synthesis without meta-analysis (SWiM) approach was applied. The GRADE approach was used to assess the certainty of evidence for each outcome.
MAIN RESULTS
Nine studies (614 participants) were included in the review. All were RCTs of parallel design, wherein female patients aged > 18 years underwent breast cancer surgery under paravertebral anaesthesia or general anaesthesia. None of the studies assessed quality of recovery in the first three postoperative days using a validated questionnaire; most assessed factors affecting quality of recovery such as postoperative analgesic use, postoperative nausea and vomiting (PONV), hospital stay, ambulation, and patient satisfaction. Paravertebral anaesthesia may reduce the 24-hour postoperative analgesic requirement (odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01 to 0.34; 5 studies, 305 participants; low-certainty evidence) compared to general anaesthesia. Heterogeneity (I² = 70%) was attributed to the fixed dose of opioids and non-steroidal analgesics administered postoperatively in one study (70 participants), masking a difference in analgesic requirements between groups. Paravertebral anaesthesia probably reduces the incidence of PONV (OR 0.16, 95% CI 0.08 to 0.30; 6 studies, 324 participants; moderate-certainty evidence), probably results in a shorter hospital stay (mean difference (MD) -79.39 minutes, 95% CI -107.38 to -51.40; 3 studies, 174 participants; moderate-certainty evidence), and probably reduces time to ambulation compared to general anaesthesia (SWiM analysis): percentages indicate vote counting based on direction of effect (100%, 95% CI 51.01% to 100%; P = 0.125; 4 studies, 375 participants; moderate-certainty evidence). Paravertebral anaesthesia probably results in higher patient satisfaction (MD 5.52 points, 95% CI 1.30 to 9.75; 3 studies, 129 participants; moderate-certainty evidence) on a 0 to 100 scale 24 hours postoperatively compared to general anaesthesia. Postoperative pain at rest and on movement was assessed at 2, 6, and 24 postoperative hours on a 0 to 10 visual analogue scale (VAS). Four studies (224 participants) found that paravertebral anaesthesia as compared to general anaesthesia probably reduced pain at 2 postoperative hours (MD -2.95, 95% CI -3.37 to -2.54; moderate-certainty evidence). Five studies (324 participants) found that paravertebral anaesthesia may reduce pain at rest at 6 hours postoperatively (MD -1.54, 95% CI -3.20 to 0.11; low-certainty evidence). Five studies (278 participants) found that paravertebral anaesthesia may reduce pain at rest at 24 hours postoperatively (MD -1.19, 95% CI -2.27 to -0.10; low-certainty evidence). Differences in the methods of two studies (119 participants) and addition of clonidine to the local anaesthetic in two studies (109 participants), respectively, contributed to the heterogeneity (I² = 96%) observed for these two outcomes. Two studies (130 participants) found that paravertebral anaesthesia may reduce pain on movement at 6 hours (MD-2.57, 95% CI -3.97 to -1.17) and at 24 hours (MD -2.12, 95% CI -4.80 to 0.55; low-certainty evidence). Heterogeneity (I² = 96%) was observed for both outcomes and could be due to methodological differences between studies. None of the studies reported mortality related to the anaesthetic technique. Eight studies (574 participants) evaluated adverse outcomes with paravertebral anaesthesia: epidural spread (0.7%), minor bleeding (1.4%), pleural puncture not associated with pneumothorax (0.3%), and Horner's syndrome (7.1%). These complications were self-limiting and resolved without treatment. No data are available on disease-free survival, chronic pain, and quality of life. Blinding of personnel or participants was not possible in any study, as a regional anaesthetic technique was compared to general anaesthesia. Risk of bias was judged to be serious, as seven studies had concerns of selection bias and three of detection bias.
AUTHORS' CONCLUSIONS
Moderate-certainty evidence shows that paravertebral anaesthesia probably reduces PONV, hospital stay, postoperative pain (at 2 hours), and time to ambulation and results in greater patient satisfaction on the first postoperative day compared to general anaesthesia. Paravertebral anaesthesia may also reduce postoperative analgesic use and postoperative pain at 6 and 24 hours at rest and on movement based on low-certainty evidence. However, RCTs using validated questionnaires are needed to confirm these results. Adverse events observed with paravertebral anaesthesia are rare.
Topics: Adult; Analgesia; Anesthesia Recovery Period; Anesthesia, General; Anesthesia, Spinal; Bias; Breast Neoplasms; Early Ambulation; Female; Horner Syndrome; Humans; Incidence; Intention to Treat Analysis; Length of Stay; Nerve Block; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Postoperative Nausea and Vomiting; Randomized Controlled Trials as Topic; Stress, Physiological
PubMed: 33629404
DOI: 10.1002/14651858.CD012968.pub2