Neurohospitalist最新文献

Background and purpose: Recently, institutions have been transitioning to tenecteplase (TNK) as the primary agent for stroke management instead of alteplase (tPA) due to its comparable safety and cost-effectiveness. Despite TNK's potential cost benefits, there's limited literature on how wasted doses impact the overall cost. This study aimed to compare the safety and cost of TNK to tPA following the transition to TNK as the primary agent for acute ischemic stroke (AIS) management at a community hospital.

Methods: This retrospective study compared patients treated with tPA or TNK for AIS. The primary outcome was a composite of intracranial hemorrhage, any other bleed, and death from any cause. Secondary outcomes included the individual components of the primary outcome, length of hospitalization, time from administration decision to medication administration, readmission rate, medication costs, and wasted doses.

Results: 48 AIS patients who received either tPA or TNK between November 2021 and February 2024 were included. TNK didn't result in more occurrences of the primary outcome compared to tPA (OR 1.00, 95% CI 0.25 to 4.03). The TNK group had a shorter median length of hospitalization and decreased elapsed time from administration decision to administration. The cost difference between a 50 mg kit of TNK and a 100 mg vial of tPA is about $1100. The total number of wasted doses was 10 for tPA and 12 for TNK.

Conclusions: There was no difference in safety between TNK and tPA. While TNK offers cost savings, poor waste management could undermine its overall cost-effectiveness.

Our case report presents the clinical management of a 77-year-old female with recurrent acute ischemic stroke (AIS) due to severe intracranial large artery atherosclerosis (LAA), requiring intracranial stenting complicated by new-onset atrial fibrillation (AF). This clinical scenario necessitated the use of triple antithrombotic therapy (TAT) with aspirin, ticagrelor, and apixaban. While guidelines recommend minimizing the duration of TAT or favoring alternative regimens due to bleeding risks, this case highlights the safe application of an extended duration TAT course in a high-risk patient. The patient initially presented with recurrent AIS despite dual antiplatelet therapy (DAPT). Subsequent intracranial stenting and AF diagnosis posed challenges in balancing ischemic and bleeding risks. Multidisciplinary, shared decision-making guided the initiation of TAT. Despite a history of early recurrent strokes and high-risk stenting, no major, life-threatening, or minor bleeding complications were observed during the extended duration of TAT. This case underscores the need for tailored antithrombotic regimens in neurovascular patients with AF and high ischemic risk.

Objective: To examine the association between housing status and healthcare utilization in individuals presenting with seizure.

Methods: We performed a retrospective cross-sectional analysis of all adults (age >18) presenting to a public hospital emergency department with seizures, defined by ICD-9/10 codes, between 1/1/2016 and 8/03/2019. They were categorized by housing status (people experiencing homelessness [PEH], people with housing). Healthcare utilization outcomes were 30-day re-visit to acute care, discharge disposition, and hospital length of stay for those admitted. We used multivariable linear and logistic regression models adjusting for age, comorbidities, and insurance status.

Results: There were 6483 individuals (2092 [32.3%] PEH). Compared to people with housing, PEH were younger (48.2 vs 50.9, P < .0001), more likely to be a person of color (80.9 vs 75.1%, P < .0001), and have Medicaid (51.4% vs 42.9%, P < .0001). People with housing had a higher prevalence of admission to the intensive care unit (3.6% vs 1.8%, P < .0001). After adjustment, admitted PEH had higher odds of 30-day re-visit (adjusted odds ratio [aOR] 1.87, 95% confidence interval [CI] 1.58, 2.21), shorter length of stay (coef Β-12.87, 95% CI: -22.62, -3.11), and lower odds of being discharged to a facility (aOR 0.37, 95% CI: .26, .55) compared to people with housing.

Conclusion and relevance: PEH with seizures had increased healthcare utilization. Further analysis, including imaging findings, anti-seizure medications prescribed, and presumed etiology, is needed to understand the drivers of healthcare utilization and identify appropriate interventions.

Background and Objectives: We report a rare case of severe posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) in an adult patient with hemophagocytic lymphohistiocytosis (HLH), and speculate that these three diagnoses are related by similar mechanisms of vascular endothelial dysfunction. Methods: Informed consent for this case report was obtained from the patient's legally authorized surrogate decision maker. Discussion and Practical Implications: Our patient initially presented with HLH secondary to intra-abdominal sepsis, and was later found to have severe PRES and RCVS resulting in extensive border-zone cortex infarction. Improvement of the severe systemic inflammatory syndrome characteristic of HLH and arrest of PRES and RCVS progression occurred only after HLH-specific treatment was initiated. In addition to illustrating the potential of HLH to manifest as PRES and RCVS, this case emphasizes the importance of prompt recognition and treatment of HLH and the role the neurologist can play in this process. This case also sheds light on the pathophysiological links between PRES, RCVS, and HLH. These three diagnoses may be related by similar mechanisms of vascular endothelial dysfunction caused by uncontrolled and severe systemic inflammation.

Background: Nonmydriatic ocular fundus photography has been studied with demonstrated benefit in the evaluation of emergency department neurological complaints, particularly in triaging headache and focal neurological deficits. Likewise, portable fundus camera usage may be practical for inpatients with neurological complaints, although feasibility has not been studied in a neurology teaching service. Purpose: The objective of this study is to determine if a portable, nonmydriatic fundus camera could be integrated into routine clinical care by neurology inpatient housestaff at a tertiary medical center. Research Design: Housestaff were asked to obtain fundus photographs for patients with specific indications for fundoscopy. Study Sample: During a 1-month pilot period, housestaff were successfully able to upload images from 21 patients, which were reviewed by a neuro-ophthalmology attending, with input from on-call ophthalmology if desired. Results: Surveys of housestaff before (n = 13) and after (n = 12) implementation demonstrated increased confidence in camera operation and in ocular structure identification, description, and interpretation. Thematic analysis on qualitative feedback suggested benefits in clinical (improving fundus visualization, aiding in triage, sharing images with offsite staff), health systems (reducing length of stay, reducing ophthalmology consultations, reduced unnecessary testing), and educational domains (facilitating group discussions of images, sharing photographs with patients). Conclusions: Overall, inpatient portable fundus photography was shown to be feasible and effective for rapid fundus visualization for neurological inpatients, enhancing the ability to share, document, and compare examinations among neurology housestaff. Further work is needed to confirm clinical and educational benefits of portable fundus photography usage by neurology residents, as suggested by this healthcare quality improvement pilot study.

Background/objectives: There is currently no consensus regarding the optimal strategy for reversal of anticoagulation in life-threatening hemorrhage associated with factor XIa (FXIa) inhibitors.

Methods: For this clinical case report, informed consent was obtained from surrogate.

Results and discussion: Here, we present the case of an 82-year-old female who sustained a large subdural hematoma after a fall. Her aPTT on admission was elevated at 90.4 s and remained persistently prolonged at 90.9 s 12-hour after receiving an adequate dose of 4-factor prothrombin complex concentrate (PCC). She was found to have received a factor XIa inhibitor in a clinical trial, and subsequently received recombinant activated factor VII (rFVIIa) 2 mg (45 mcg/kg) as a one-time dose, and tranexamic acid (TXA) 1 g intravenously for reversal given her intracranial bleeding in the setting of trauma complicated by recent factor XIa inhibitor use. However, given her clinical decline and high surgical risk, the patient's family elected to withdraw care and she expired three days later. Reversal of FXIa inhibitors is challenging but may best be achieved using a combination of rFVIIa and TXA.

Practical implications: Clinicians should consider administration of low dose recombinant activated factor VII (rFVIIa) in conjunction with an anti-fibrinolytic inhibitor such as tranexamic acid (TXA) for reversal of life-threatening hemorrhage in bleeding patients with exposure to novel factor XIa inhibitors that are currently in clinical trials.

Introduction: Post-Traumatic Stress Disorder (PTSD) is associated with exposure to traumatic events, especially in the military setting. However, patients who experience stroke may develop anxiety about their stroke event and may re-experience transient neurological symptoms as a result. A significant portion develop the persistent and disabling symptoms of PTSD.

Methods: At the University of South Florida, we conducted a single-center, IRB-approved, observational pilot study of 20 adult patients who were diagnosed with stroke or transient ischemic attack (TIA) in the previous 31 days to 1 year. Patients completed the post-traumatic stress disorder checklist-5 (PCL-5), Patient Health Questionnaire-9 (PHQ-9), Stroke specific Quality of Life Scale (SS-QOL-12), Modified Rankin Scale of disability (mRS), and National Institutes of Health Stroke Scale (NIHSS) and provided blood and saliva samples.

Results: All 20 subjects completed the PCL-5 and 19 subjects completed the follow up scales. Seven patients (35%) were found to have Post-Stroke Post-Traumatic Stress Disorder (PS-PTSD). Higher PCL-5 scores were significantly correlated with lower SS-QOL scores indicating worse quality of life (r = -0.709, P = .001) and higher PHQ-9 scores representing symptoms of depression (r = 0.727, P < 0.001).

Conclusion: Post-Stroke Post-Traumatic Stress Disorder (PS-PTSD) is prevalent after stroke and TIA with patients experiencing concurrent depressive symptoms, correlating with a worsened quality of life.

Subacute-to-chronic gait instability has a broad differential diagnosis. The neurological exam can help elucidate the localization and suggest an underlying etiology of the symptomatology, which can lead to a more focused diagnostic approach. Two patients are described - 1 with a month of worsening difficulty with ambulation that evolved to bilateral hand discoordination and another with 18 months of progressive difficulty with ambulation that also then progressed to involve her bilateral hands. These cases highlight an approach to gait dysfunction with hand discoordination secondary to sensory ataxia. The patients were ultimately diagnosed with copper deficiency myelopathy secondary to zinc excess, and different treatment regimens are discussed.