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Local anesthetics are commonly administered by nuchal infiltration to provide a temporary interscalene brachial plexus block (ISB) in a surgical setting. Although less commonly reported, local anesthetics can induce central nervous system toxicity. In this case study, we present three patients with acute central nervous system toxicity induced by local anesthetics applied during ISB with emphasis on neurological symptoms, key neuroradiological findings and functional outcome. Medical history, clinical and imaging findings, and outcome of three patients with local anesthetic-induced toxic left hemisphere syndrome during left ISB were analyzed. All patients were admitted to our neurological intensive care unit between November 2016 and September 2019. All three patients presented in poor clinical condition with impaired consciousness and left hemisphere syndrome. Electroencephalography revealed slow wave activity in the affected hemisphere of all patients. Seizure activity with progression to status epilepticus was observed in one patient. In two out of three patients, cortical FLAIR hyperintensities and restricted diffusion in the territory of the left internal carotid artery were observed in magnetic resonance imaging. Assessment of neurological severity scores revealed spontaneous partial reversibility of neurological symptoms. Local anesthetic-induced CNS toxicity during ISB can lead to severe neurological impairment and anatomically variable cerebral lesions.
Afterimages result from a prolonged exposure to still visual stimuli. They are best detectable when viewed against uniform backgrounds and can persist for multiple seconds. Consequently, the dynamics of afterimages appears to be slow by their very nature. To the contrary, we report here that about 50% of an afterimage intensity can be erased rapidly—within less than a second. The prerequisite is that subjects view a rich visual content to erase the afterimage; fast erasure of afterimages does not occur if subjects view a blank screen. Moreover, we find evidence that fast removal of afterimages is a skill learned with practice as our subjects were always more effective in cleaning up afterimages in later parts of the experiment. These results can be explained by a tri-level hierarchy of adaptive mechanisms, as has been proposed by the theory of practopoiesis.