Blaauw G* and Muhlig RS
In this short review article we wish to present our attitude to the indications and management of obstetric brachial plexus palsy cases based on our experience with more than 500 children. A great many international meetings and repeated discussions with colleagues concerning the subject have taken place in the past years.
Intercostal neuralgia is pain in the thoracic region emanating from an intercostal nerve. It occurs commonly after thoracotomy. It can also be seen in elderly debilitated patients without a known precipitating event, other causes include rib trauma, very rarely benign periosteal lipoma and pregnancy. Intercostal neuralgia due to surgical injury of the intercostal nerve has traditionally been difficult to treat. No single treatment modality has been curative. There are several treatment options available, including systemic medications, topical or invasive nerve blocks, cryoablation, and radio ablation. Despite numerous treatment advances, many patients remain refractory to the current therapies and continue to have pain, physical and psychological distress. In this review, we will discuss the pathophysiology of intercostal neuralgia, its clinical manifestations, diagnosis and various pharmacological, non-pharmacological and interventional treatment modalities, as also the insight into the potential complications of the disease and treatment modalities.
Muhammad Shah Miran*, Leah Roering, Alberto Maud, Michelle Peterson, Kenneth Shea, and M Fareed K Suri
Background: Intravenous (IV) alteplase is not recommended in acute ischemic stroke patients with concurrent infective endocarditis (AIS-IE) due to high rates of hemorrhagic conversion, death, and disability.
Methods: We report a case in which a patient received IV alteplase and was later diagnosed with possible infective endocarditis. Previously published literature regarding similar cases and articles on PubMed was also reviewed.
Case summary: A 36-year-old male patient with no history of hypertension, diabetes, a trial fibrillation, hyper lipidemia, or other classic risk factors for stroke presented to the emergency room (ER) with a sudden onset of left hemiparesis, numbness, and left facial droop. NIHSS at admission was 10. His blood pressure was 137/100 mmHg, temperature 98.1 F, respiratory rate 23, and pulse 105. His WBC count was 13.8 K/UL. Physical exam was negative for cardiac murmurs, fever, and vascular stigmata associated with IE. Patient had a history of migraine headaches, but denied headache at the time of presentation. Per the patient's history, he had suffered a low-grade fever for the past few days which he had attributed to West Nile fever. Patient's history was negative for seizures and stroke. Initial computed tomography (CT) of the head was negative for any bleeding. Patient was assessed and administered IV alteplase (0.9mg/kg) within the American Heart Association's (AHA) time frame recommendations (67 minutes from onset of symptoms). The next day the patient's hemiparesis resolved with NIHSS of 0. Considering his reported history of low-grade fevers in conjunction with multiple small infarcts revealed on his MRI, infective endocarditis (IE) was investigated as a possible cause of the embolic stroke. Blood cultures were positive for gram positive cocci in clusters. Follow-up imaging revealed asymptomatic hemorrhagic conversion. IV Penicillin G was initiated and prescribed for six weeks.
Conclusion: While evaluating young AIS patients for IV alteplase, who present without classic stroke risk factors, a thorough history and clinical exam with a specific focus on the signs and symptoms of IE, systemic inflammatory response syndrome (SIRS), and other embolic diseases can help reduce hemorrhagic complications. Absence of fever, vascular stigmata, and cardiac murmur at presentation does not necessarily exclude the possibility of IE. Afebrile patients who report a recent history of fever warrant caution before treatment with thrombolytics.