Management of a Difficult Airway Scenario in a Case of Hurler’s Syndrome with a D-Blade Video Laryngoscope

Hurler’s syndrome is a rare genetic disease characterized by progressive multiorgan accumulation of glycosaminoglycans. It is associated with progressive craniofacial, skeletal, and cardiac involvement, which increases the risk of anesthesia. Patients with Hurler’s syndrome could present as the worst airway management problem an anesthesiologist could deal with due to abnormal upper airway anatomy and limited neck manipulation, owing to the atlantoaxial instability. We report a case of difficult airway scenario of a child with Hurler’s syndrome, leading to an apparent cannot ventilate cannot intubate scenario, which was managed successfully with the help of a C-MAC video laryngoscope with unique D-blade. In Hurler’s syndrome, C-MAC with D-blade is an excellent tool in establishing an airway in a pediatric difficult airway scenario. Moreover, D-blade C-MAC could be considered as the primary tool for establishing an airway in pediatric patients with Hurler’s syndrome.

Abstract TP220: Differential Risk Factors and Outcomes of Ischemic Stroke Due to Cervical Artery

Introduction: Cervical artery dissection (CeAD) is a major cause of acute ischemic stroke (AIS) in young adults. Its pathophysiology is distinct from the other etiologies of AIS and is determined by both genetic and environmental factors. In this study, we sought to determine the risk factors for and outcomes of AIS due to CeAD in young adults, in the era of increasing utilization of neuroimaging and neuro-intervention procedures. Methods: We retrospectively reviewed all cases of AIS between 15-45 years of age admitted to our comprehensive stroke center between January 2010 - November 2016. Risk factors and outcomes were compared between patients with and without CeAD using univariate analysis. Multivariable generalized linear and logistic regression models were used to adjust for confounding variables. Results: Of the total 333 patients with AIS included in the study (mean±SD age: 36.4±7.1 years; females 50.8%), CeAD was identified in 84 (25.2%) patients. When compared to the non-CeAD group, patients with CeAD were younger in age and more likely to have a history of migraine and recent chiropractic neck manipulation (p<0.05). Risk factors including hypertension, diabetes, hyperlipidemia and obesity were more prevalent in the non-CeAD group (p<0.05). Patients with CeAD had shorter hospital stay by an average of 1.8 days (95% CI=0.3-3.4, p<0.05), however, this difference was not statistically significant after adjustment for initial NIHSS score, age, gender, and comorbidities. Patients with CeAD were more likely to have worse functional outcome at discharge, defined as modified Rankin scale score (mRS) ≥3, independent of the above confounding variables (adjusted odds ratio 3.6, 95% CI=1.6-8.1). The in-hospital mortality rate, discharge disposition, mRS score and recurrence rates at follow-up (mean time 4.2 months) were similar between the two groups. Conclusions: While history of migraine and recent chiropractic neck manipulation are significantly associated with CeAD; most of the traditional vascular risk factors are less prevalent in this group. In comparison with AIS due to other etiologies, patients with CeAD have worse functional outcomes at the time of discharge but similar outcomes at follow up, which suggests a propensity for better recovery.

A rare case of ischaemic stroke following cervical spine manipulation in an adolescent girl

Stroke in children is associated with a multitude of risk factors compared to risk factors of adult stroke such as hypertension, diabetes or atherosclerosis. A 15-year adolescent girl presented with acute onset weakness involving right upper and lower limb. She complained of neck pain and fever 2 days before the onset of hemiparesis for which her parents took her to traditional healer who performed neck manipulation after which she developed vomiting, tingling numbness and weakness of right upper and lower limb. There was no history of preceding headache, ear discharge or any other contributory history. Clinical examination revealed Glasgow Come Scale 12/15, power of grade 2/5 in right upper limb and 3/5 in right lower limb, exaggerated deep reflexes, extensor plantar reflex, right sided ptosis and right sided upper motor neuron facial palsy. CT scan brain showed right cerebellar and occipital infarct with posterior inferior cerebellar artery territory involvement. MRI Brain and MR Angiogram showed wedge shaped infarct involving right posterior inferior cerebellum, inferior vermis, ventral aspect of superior medulla, paracentral pons, right cerebral peduncle, tectum of both halves of midbrain with no internal hemorrhage and no vessel abnormality and right vertebral artery was not visualized. Her coagulation profile and cardiac work up were normal. She was treated with antiplatelet drugs, anticoagulants and physiotherapy following which the child gradually improved over a period of one month. In this case, with a positive history of neck manipulation authors can conclude that the etiology of young stroke wasinduced byneck manipulation. This case has been reported to increase awareness about the ill effects of neck manipulation and counsel parents against performing such procedures for children. Early recognition of pediatric stroke is critical for immediate diagnosis, imaging and treatment with better outcomes.

Differential Risk Factors and Outcomes of Ischemic Stroke due to Cervical Artery Dissection in Young Adults

<b><i>Introduction:</i></b> Cervical artery dissection (CeAD) is a major cause of ischemic stroke in young adults. Our understanding of the specific risk factors and clinical course of CeAD is still evolving. In this study, we evaluated the differential risk factors and outcomes of CeAD-related strokes among young adults. <b><i>Methods:</i></b> The study population consisted of young patients 15–45 years of age consecutively admitted with acute ischemic stroke to our comprehensive stroke center between January 1, 2010, and November 30, 2016. Diagnosis of CeAD was based on clinical and radiological findings. Univariate and multivariable logistic regression analyses were used to assess the risk factors and clinical outcomes associated with CeAD-related strokes. <b><i>Results:</i></b> Of the total 333 patients with acute ischemic stroke included in the study (mean ± SD age: 36.4 ± 7.1 years; women 50.8%), CeAD was identified in 79 (23.7%) patients. As compared to stroke due to other etiologies, patients with CeAD were younger in age, more likely to have history of migraine and recent neck manipulation and were less likely to have hypertension, diabetes, and previous history of stroke. Clinical outcomes of CeAD were comparable to strokes due to other etiologies. Within the CeAD group, higher initial stroke severity and history of tobacco use were associated with higher modified Rankin Scale score at follow-up. <b><i>Conclusions:</i></b> While history of migraine and neck manipulation are significantly associated with CeAD, most of the traditional vascular risk factors for stroke are less prevalent in this group when compared to strokes due to other etiologies. For CeAD-related strokes, higher initial stroke severity and history of tobacco use may be associated with higher stroke-related disability, but overall, patients with CeAD have similar outcomes as compared to strokes due to other etiologies.

Cervical epidural hematoma after spinal manipulation therapy: a case report

Background Cervical spinal manipulation therapy is a common non-invasive treatment for neck pain and stiffness, and has been widely used in the population. However, most people do not pay attention to the potential risks of neck manipulation, such as ligament damage, fractures, and spinal cord injuries. Epidural hematoma is a disease in which blood accumulates in the epidural space of the vertebral body. This disease is usually caused by trauma or iatrogenic surgery, and may be associated with blood coagulopathies, neoplasms, or degenerative spinal disease. Reports of epidural hematoma caused by cervical spinal manipulation are rare. Case presentation We present the case of a patient with tetraplegia and spinal shock after neck manipulation. A physical examination of the patient on admission found tenderness in the neck and increased muscle tension in both upper limbs. The superficial sensation of the upper limb disappeared, but the deep sensation still remained. The lower extremity had 0/5 power on both sides. The sensation below the T2 level completely disappeared. A cervical magnetic resonance imaging scan showed an acute posterior epidural hematoma from the C3–T3 vertebrae. Ultimately, the patient underwent emergency hematoma removal and showed partial improvement in symptoms of paralysis during follow-up. Conclusions Although spinal manipulation is simple and neck pain is common and recurrent in the general population, the basic condition and disease history of patients should be determined before manipulation. For high-risk patients, caution should be applied for cervical spinal manipulation or it should be prohibited. For a suspected hematoma, MRI should be used at an early stage to diagnose and locate the hematoma.

Spinal epidural hematoma in a patient on chronic anticoagulation therapy performing self-neck manipulation: a case report

Background Spinal epidural hematoma is a rare condition usually secondary to trauma and coagulopathy. To the best of our knowledge, we present the first case of a patient with an iatrogenic hypercoaguable state performing self-neck manipulation, which resulted in a spinal epidural hematoma and subsequent quadriparesis. Case presentation A 63-year-old man presented to the emergency department with worsening interscapular pain radiating to his neck 1 day after performing self-manipulation of his cervical spine. He was found to be coagulopathic upon admission, secondary to chronic warfarin therapy for the management of atrial fibrillation. Approximately 48 h after the manipulation, the patient became acutely quadriparetic and hypotensive. Urgent magnetic resonance imaging revealed a multilevel spinal epidural hematoma from the lower cervical to thoracic spine. Conclusions Partial C7, complete T1 and T2, and partial T3 bilateral laminectomy was performed for evacuation of the spinal epidural hematoma. Following a 2-week course of acute inpatient rehabilitation, the patient returned to his baseline functional status. This case highlights the risks of self-manipulation of the neck and potentially other activities that significantly stretch or apply torque to the cervical spine. It also presents a clinical scenario in which practitioners of spinal manipulation therapy should be aware of patients undergoing anticoagulation therapy.

Ischemic Stroke Secondary to Stylocarotid Variant of Eagle Syndrome

Eagle syndrome is a rare cause of stroke and results as a complication of the elongated styloid process (ESP), which can cause carotid dissection and consequent ischemic stroke. We report a case of a 42-year-old woman with a past medical history of rheumatoid arthritis who developed left hemispheric ischemic stroke after deep tissue massage. Imaging studies revealed an intimal tear of the left carotid artery bulb and bilaterally ESPs, measuring approximately 6 cm on the right and 4.5 cm on the left. It seems that direct vascular compromise by the anomalous styloid process was the cause of her carotid artery dissection and stroke. Moreover, neck manipulation may have been a contributing factor.