Neurohospitalist最新文献

Background and objectives: Coccidioidal vasculitis is a serious complication of coccidioidal infection. Prior studies suggest that steroids may reduce the risk of secondary vasculitis in coccidioidal meningitis (CM), but data on optimal dosing are limited. This study compared the characteristics and outcomes of CM patients with vasculitis who received different steroid doses.

Methods: The Stanford Research Data Repository was used to identify adult patients diagnosed with coccidioidal meningitis from 1992 to 2024. Patients were divided into those who received no steroids, low or medium dose steroids, and high dose steroids. Characteristics at admission were compared by steroid use category, and their association with clinical outcomes were assessed.

Results: A total of 65 patients with CM were identified, with mean (standard deviation) age 45 (17) and 35% female. A higher percentage of patients not treated with steroids had a better modified Rankin score (mRS) of 2 or lower on admission compared to patients who were treated with steroids (standardized mean difference [SMD] = 0.67). Compared to patients who received a low/medium dose, those who received a high dose were 32% (95% CI 0.12, 3.61; P = 0.65) less likely to experience death or vasculitis.

Discussion: There is a complex relationship between the use of steroids and outcomes among patients with CM. Among steroid recipients, those who received high dose steroids may achieve better long-term outcomes. A larger study is needed to validate these findings.

Background/purpose: Data analyzing usage patterns, efficacy, tolerability, and long-term continuation of brivaracetam (BRV) when initiated in the acute, inpatient setting is lacking.

Methods: Retrospective chart review of adult patients who initiated BRV in the emergency or inpatient setting at Yale New Haven Hospital over 5-year span.

Results: Of 133 patients, BRV was used for status epilepticus (SE) in 37% (n = 49), seizures in 38% (n = 51), and rhythmic/periodic patterns (RPP) in 21% (n = 28). Eighty-six (65%) were in an ICU and 33 (25%) were in a non-ICU setting. BRV was the first anti-seizure medication (ASM) tried in 9 (7%), while 124 (93%) tried other ASMs first (mean ASMs = 2; SD = 1). Initial dosing ranged from 50-400 mg (median = 200 mg, IQR = 200-300 mg), then median maintenance dosing of 200 mg/day (IQR = 200-300 mg/day). Of patients with RPP, seizures, or SE on EEG (n = 115, 86%), 46% (n = 53) had electrographic and/or clinical improvement, including 23 (20%) with complete resolution. In patients with clinical seizures (n = 10) or SE (n = 2) not on EEG, BRV was effective in 10 patients. BRV was discontinued in 49 (36%) patients, typically for inefficacy. Of 88 survivors to discharge, 86 (98%) were discharged on ASMs, including 62% (n = 54) discharged on BRV. Follow-up data were available for 53 (60%) patients - 51 (96%) remained on ASMs, with 33 (65%) remaining on BRV (median follow-up = 30 d, IQR = 18-65 d).

Conclusions: BRV appears safe, well-tolerated, and efficacious for acute, inpatient management of RPP, seizures, and SE. Prospective studies validating these findings and directly comparing BRV with other ASMs are warranted.

Background: CTP has increasingly been incorporated into the evaluation of all patients with suspected acute ischemic stroke (AIS), including those with minor symptoms. We aimed to assess the frequency with which CTP is performed in patients with possible AIS based on NIHSS as well as the role of CTP in acute treatment decision-making among patients with low NIHSS.

Methods: We performed a retrospective cohort study of all patients who underwent CTP upon presentation to the ED at 3 academic, urban hospitals in Philadelphia, PA between January 1, 2022 and December 31, 2022. We collected data on initial NIHSS score, AIS treatment decisions, subsequent neuroimaging, and final diagnosis. The study was deemed exempt by the Hospital of the University of Pennsylvania IRB.

Results: There were 530 patients with a median age of 65 years (IQR 54-73) and 56% were women. The frequency of CTP by NIHSS is displayed in the figure. A total of 89 CTP studies (16.8%) were performed in patients with very low NIHSS (defined as NIHSS ≤ 2). Of these, just 2 (2.2%) received thrombolysis and 0 (0%) received thrombectomy. CTP did not influence the treatment decision in either case.

Conclusions: CTP is frequently performed in patients with low NIHSS. It had limited impact on acute treatment decisions, notably none among those with NIHSS ≤ 2, suggesting that CTP may be over-utilized in this subset of patients with AIS.

Background: Stress-induced hyperglycemia (SIH) has been associated with poor outcomes in stroke patients. However, the relationship between SIH and sepsis in this population remains understudied. We aimed to evaluate the association of SIH, measured using the stress hyperglycemia ratio (SHR), with the development of sepsis and mortality among critically ill stroke patients.

Methods: We retrospectively analyzed stroke patients requiring ICU admission from the MIMIC-IV database. Primary outcome was sepsis, and secondary outcomes were 30-day and 90-day all-cause mortality. Multivariable Cox and logistic regression models were used to evaluate associations.

Results: A total of 3018 patients were included (66.8% ischemic stroke). After full adjustment for confounders, SHR was independently associated with an increased risk of sepsis (Q4 vs Q1: OR 1.46, 95% CI: 1.12-1.89, P = 0.005; continuous SHR: OR 1.31, P = 0.010). SHR also demonstrated a strong dose-response relationship with mortality; patients in Q4 had significantly higher risks of 30-day (OR 2.95, 95% CI: 2.25-3.88, P < 0.001) and 90-day mortality (OR 2.25, 95% CI: 1.80-2.82, P < 0.001). Subgroup analyses revealed significant interactions between SHR and stroke type for sepsis (P for interaction = 0.014), with a more pronounced effect observed in ischemic stroke patients. The associations between SHR and both sepsis and mortality were consistently maintained regardless of the presence of diabetes (all P < 0.050).

Conclusion: Elevated stress hyperglycemia ratio is independently associated with higher risks of sepsis and short-to long-term mortality among critically ill patients with stroke, with consistent associations observed irrespective of diabetes status. In contrast, no statistically significant association between SHR and sepsis was identified in the hemorrhagic stroke subgroup.

Background and purpose: A national survey was conducted among members of the Neurohospitalist Society (NHS) to characterize updated practice patterns, perspectives, compensation, and career satisfaction of neurohospitalists in the U.S.

Methods: Between March and May 2024, a 96-question online survey was distributed. Findings were compared to those from a similar NHS survey conducted in 2016.

Results: 143 neurohospitalists completed the survey (response rate 19%). 80% had some fellowship training, with vascular neurology (35%) and neurohospitalist (17%) being most common. 60% were ≤10 years out of completion of training, and 68% had ≤10 years of practice experience. 76% worked in academic medical centers and 24% in community hospitals. Cerebrovascular disease, seizure, and delirium/encephalopathy were the 3 most common neurological diagnoses seen in the inpatient setting. The most frequent work schedule (≥44%) was 7 days on/7 days off. The most common compensation model was base salary plus incentives (≥58%). For neurohospitalists working for academic medical centers, median total annual compensation was $299 250 (IQR $100 000). For neurohospitalists with non-academic employers, median total compensation was $367 000 (IQR $98 000). 70% of academic neurohospitalists and 53% of community neurohospitalists reported working with non-physician practitioners (NPPs). Although 64% of neurohospitalists reported having experienced burnout, 91% agreed that they find their clinical work personally rewarding.

Conclusions: This survey, the largest to date among neurohospitalists, confirms that neurohospitalists remain a diverse, relatively young workforce with national presence. When compared to the 2016 survey, neurohospitalist compensation has increased.

Background and purpose: Insulin Resistance (IR) impact on Acute Ischemic Stroke (AIS) outcomes has been challenging to assess due to the lack of a readily available IR biomarker in acute settings. The Triglyceride-Glucose (TyG) index is a novel surrogate marker for IR that may help bridge this gap. We aimed to evaluate the relationship between IR and clinical outcomes after AIS in patients with large vessel occlusion (LVO).

Methods: This single-center retrospective cohort study included patients presenting between 2010 and 2022 with internal carotid artery (ICA) or middle cerebral artery (M1) occlusion who underwent endovascular treatment (EVT). Eligibility criteria were: pre-stroke modified Rankin Scale (mRS) score ≤2 and available fasting triglyceride and glucose levels. The TyG index was calculated as Ln [triglyceride (mg/dL) × glucose (mg/dL)]/2. Multivariable ordinal logistic regression was performed to assess the association between the TyG index and other demographic variables on 90-day mRS.

Results: Among 155 patients, 53% were males, and 47% were females. TyG index was significantly associated association with 90-day mRS (OR = 2.04, P < 0.01). Other associated variables included age (OR = 1.05, P < 0.01) and smoking status, with former smokers having lower odds of worse outcomes (OR = 0.44, P = 0.03).

Conclusion: Lower TyG index values, indicative of reduced IR, were associated with better functional outcomes following EVT in AIS patients with LVO. Future studies should establish optimal TyG index cut-off values to refine vascular risk management and improve stroke outcomes.

Individuals with Alice in Wonderland syndrome can present with a wide variety of visual symptoms. Most commonly, visual disturbances in size perception such as micropsia or macropsia are observed. However, rarer disturbances such as the visual perception of multiple images, termed polyopia, as well as kinetopsia, a visual illusion in which stationary objects are perceived as moving, have also been described. Previous neuroimaging of different individuals with Alice in Wonderland syndrome has shown the involvement of topographically separate brain regions. Here, we describe an individual who sequentially developed both micropsia and concurrent polyopia with kinetopsia following multi-focal infarction from underlying endocarditis. We show and describe his neuroimaging findings, as well as contextualize this with recent work showing how Alice in Wonderland syndrome may be subserved by a common distributed brain network.

Background: Idiopathic intracranial hypertension (IIH) typically presents with chronic headache, pulsatile tinnitus, transient visual obscurations, and papilledema. The fulminant form, representing 2-3% of cases, is characterized by rapid visual decline within four weeks of symptom onset. Sixth cranial nerve palsy is the most frequently reported cranial neuropathy in IIH, whereas involvement of other cranial nerves is exceedingly rare.

Case presentation: We describe a 16-year-old girl with fulminant IIH and oculomotor nerve palsy associated with risperidone-induced weight gain. She presented with one week of nausea, vomiting, and occipital headache, followed by blurry vision and right ptosis. Examination revealed partial right oculomotor palsy with ptosis, a dilated pupil without a relative afferent pupillary defect, and severe bilateral papilledema. Neuroimaging excluded mass lesion, aneurysm, and inflammation, but showed findings consistent with IIH. Lumbar puncture revealed an opening pressure of 86 cm H₂O with normal CSF composition. Due to progressive symptoms, she underwent ventriculoperitoneal shunting, with near-complete resolution of oculomotor palsy and mild residual ptosis at two-week follow-up.

Conclusions: Oculomotor nerve palsy is a rare manifestation of IIH; including our case, we identified eight patients (seven female) presenting in the setting of IIH. All presented with new-onset IIH, and three were fulminant cases with markedly elevated CSF pressures (>50 cm H2O) and ultimately received shunting. Fulminant IIH should be considered in the differential diagnosis of acute oculomotor palsy, particularly when risk factors such as recent weight gain or medication use are present, as early recognition and CSF diversion are important to prevent irreversible vision or cranial nerve deficits.

Background: Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease that may affect any organ of the body. The American College of Rheumatology (ACR) defines 19 neuropsychiatric syndromes that can be directly attributed to SLE, including psychosis and movement disorder, which is most commonly chorea. Parkinsonism is exceedingly rare as a manifestation of neuropsychiatric SLE. The infrequent occurrence of parkinsonism in SLE and the lack of specific confirmatory tests can pose significant diagnostic challenges. Purpose: To describe an elderly female who presented with psychosis and acute-onset parkinsonism as the only initial clinical features of SLE. Research Design: Case report. Study Sample: A 65-year-old woman without prior autoimmune disease who presented with new-onset psychosis and rapidly progressive parkinsonism. Data Collection and/or Analysis: Clinical presentation, laboratory testing, neuroimaging, treatment course and response were reviewed and summarized. Results: The patient developed new-onset psychosis and parkinsonism. Initial imaging and CSF studies were non-diagnostic, but she later demonstrated positive anti-nuclear antibody (ANA), anti-Sm and low complement levels. She was successfully treated with plasmapheresis and immunosuppressants with complete symptom resolution. Conclusions: Psychosis and parkinsonism may be early or isolated manifestations of SLE. It is important to consider SLE and autoimmune conditions as part of the differential diagnosis in select patients presenting with psychosis and acute-onset parkinsonism as early recognition and timely immunomodulatory therapy can result in complete clinical recovery.

Background and purpose: The utilization and outcomes of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) in the presence of brain tumors has not been studied. Using the National Inpatient Sample (NIS), we performed a retrospective analysis of the rate of utilization of EVT in patients with AIS and brain tumors and their odds of in-hospital mortality and home discharge.

Methods: All adult (≥18 years) AIS patients with brain tumors of malignant, benign, or undetermined subtypes, and EVT use were identified in the NIS (2016-2019). Outcomes were odds of home discharge and in-hospital mortality, adjusted for age, sex, race, income, insurance, hospital size, intravenous tissue plasminogen activator (IV-tPA) use, and clinical severity of hospital admission.

Results: Of 533,351 AIS patients, 7070 (1.3%) had brain tumors. Sixty-two percent were malignant, 33% benign, and 5.2% undetermined. Patients with brain tumors less frequently received IV-tPA (3.4% vs 10.3%) and EVT (1.9% vs 3.6%) (P < 0.001). Home discharge after EVT was similar in patients with vs without brain tumors, for all tumor subtypes (28.0% vs 28.4%, P = 0.933). In-hospital mortality was higher with brain tumors (22.6% vs 13.0%, P < 0.001), but largely driven by malignant subtype. In adjusted analysis, only patients with malignant tumors experienced greater in-hospital death after EVT (aOR: 2.78, 95% CI: 1.61-4.80).

Conclusions: Patients with malignant brain tumors may have higher in-hospital mortality after EVT but similar rate of home discharge. These results are limited by lack of information on confounders such as brain tumor characteristics and causes of mortality in the NIS.