Neurohospitalist最新文献

Objectives: To discuss utility of using DWI-FLAIR mismatch in select patients not included in the original WAKE-UP trial for administration of IV thrombolytics.

Methods: We identified a female over 100 years old who presented with stroke symptoms upon waking up. This case is selected due to its unique management. Relevant clinical data was collected through a review of the patient's medical records. All data were anonymized to ensure confidentiality.

Results: A 102-year-old female with a complex past medical history of atrial fibrillation, not on anticoagulation presented with a National Institutes of Health Stroke Scale (NIHSS) of 23. Stroke symptoms were present upon awakening. Noncontrast computed tomography (CT) of the head was negative for hemorrhage or early ischemic changes. CT angiography (CTA) of the head and neck was notable for a distal right M2 occlusion. A hyperacute magnetic resonance imaging (MRI) of the brain was pursued to determine potential eligibility for intravenous thrombolysis (IVT). Patient consented to IVT. NIHSS improved to 13. She was eventually discharged to a skilled nursing facility.

Discussion: We aimed to highlight the oldest known case of IV thrombolysis in this patient presenting with a stroke upon awakening. This is to emphasize possible benefit in cases not included in the original WAKE-UP trial.

A 51-year-old woman presented with acute onset of a severe headache, and was found to have diffuse subarachnoid hemorrhage with prominent cisternal and left cortical convexity blood on head computed tomography. The first 2 conventional angiograms were negative for aneurysm, but a third angiogram revealed a mycotic aneurysm of a distal left middle cerebral artery branch. Brain biopsy, associated with clipping of the aneurysm, demonstrated pathology consistent with vasculitis. Over the course of a month, she developed diffuse, serpiginous dolichoectasia of the cerebral arteries. Further investigation into the cause of vasculitis supported a diagnosis of either eosinophilic granulomatosis with polyangiitis (EGPA) or IgG4-Related Disease (IgG4-RD). The following clinical pathologic conference discusses the diagnostic challenges in discriminating between these 2 diseases, particularly in the setting of secondary angiitis of the central nervous system.

Background: Monitoring stroke patients in critical-care units for 24 h after thrombolysis or endovascular thrombectomy is considered standard of care in current guidelines but is not evidence-based. Due to the COVID-19 pandemic, our center adopted a targeted protocol in April 2021 with 24-h critical-care monitoring no longer being guaranteed for stroke patients receiving reperfusion treatment. We aim to compare the incidence and timing of complications during the year under the targeted approach compared to prior years when the standard of care was followed.

Methods: We conducted a single-center retrospective cohort study. We analyzed data from stroke patients treated with thrombolysis and/or endovascular thrombectomy in 2019 (pre-COVID-19, standard of care), 2020 (during COVID-19, standard of care) and 2021 (during COVID-19, targeted protocol). Data extracted included demographics, the nature and timing of complications within the first 24 h, and the unit at the time of complication.

Results: Three hundred forty-nine patients were included in our study: 78 patients in 2019, 115 patients in 2020, and 156 patients in 2021. In 2021, 32% of patients experienced at least 1 complication within the first 24 h compared to 34% in 2020 and 27% in 2019. In 2021, 33% of patients admitted to critical-care units had a complication compared to 29% in non-critical care units. In 2021, 70% of complications had occurred by hour 8 compared to 49% in 2020 and 29% in 2019.

Conclusions: The incidence and timing of complications did not significantly worsen under the targeted approach compared to prior years and were not associated with hospital location.

Spontaneous vertical eye movements in the critical care setting are often a source of confusion and alarm; while their origin remains at least partly theoretical, understanding their classification and associated clinical implications can inform the diagnostic workup and further clinical management. This case describes a patient who demonstrated ocular dipping: slow conjugate downward eye movements with a quick return to primary gaze. Ocular dipping is a rare phenomenon that was initially described in patients with hypoxic brain injury and has since been described in only a handful of cases. Dipping resides in a spectrum of spontaneous vertical eye movements, with ocular bobbing being the first of these described eye movements. Ocular bobbing is characterized by a fast downward movement followed by a slow return to the mid gaze position which is classically associated with pontine injury. Other vertical eye movements that can be seen in patients with a disorder of consciousness include other variations of ocular bobbing and dipping, vertical myoclonus, and small-amplitude mainly vertical movements.

Background: Sialorrhea is associated with various neurological conditions. Among critically ill patients with acute neurological injuries (ANI), sialorrhea leads to several adverse consequences, including extubation failure, inability to initiate non-invasive ventilation, aspiration pneumonia and prolonged hospitalization. Botulinum toxin (BoTN) injections can reduce salivary production. Both BoTN-A and BoTN-B are effective in managing sialorrhea among patients with neurogenic dysphagia. BoTN utilization for sialorrhea in critically ill adult ANI patients is not well-studied. Purpose: The purpose of this study to evaluate the safety and feasibility of using BoTN-A salivary injections to reduce sialorrhea in ANI patients. Research Design: In this case series, we retrospectively reviewed the off-label use of BoTN-A for sialorrhea in ANI patients at the University of North Carolina Neurosciences Intensive Care Unit. Study Sample: Six patients with ANI who received BoTNA treatment for neurogenic sialorrhea in absence of infection and medications with known side-effect of sialorrhea. Data Collection: For safety evaluation, we reviewed any documented adverse effects of BoTN-A injection. For efficacy, we evaluated the drooling severity, suctioning frequency, oxygen requirements, continued days on the ventilator, and pneumonia diagnoses. Results: All patients had reduction in their documented drooling and suctioning requirements following BoTN-A injection. None had adverse events associated with BoTN-A injections. All patients experienced recurrent ventilator-associated pneumonias prior to BoTN-A injections whereas four patients had no pneumonia events after injections. Also, two patients were successfully weaned of oxygenation prior to discharge. Conclusions: This case series highlights the safety and potential efficacy of salivary gland BoTN-A for reducing refractory sialorrhea among critically ill ANI patients. Future studies are needed to evaluate whether sialorrhea reduction can lead to reduced hospital complications and overall length of hospital stay.

Streptococcus pneumoniae is the leading cause of community-acquired bacterial meningitis across all age groups. Despite appropriate antibiotic therapy, the prognosis for pneumococcal meningitis remains poor. While common acute complications include cerebral edema, brain herniation, ventriculitis, hydrocephalus, and cerebral infarctions, hemorrhagic events are rarely reported. We present a case of a young male with S. pneumoniae meningitis, who developed diffuse cerebral microhemorrhages, an extremely rare complication. Despite culture-guided antibiotic therapy, the patient's condition deteriorated, requiring mechanical ventilation. Magnetic resonance imaging revealed diffuse cerebral microhemorrhages, prompting intensive supportive care. Prolonged mechanical support and a two-week antibiotic therapy led to gradual recovery, and the patient was discharged without neurological sequelae. This case highlights the importance of early imaging and timely intervention in managing rare complications of bacterial meningitis.

Myelin oligodendrocyte glycoprotein-associated disorders (MOGAD) are autoimmune diseases that often manifest in the context of infections. They can also arise less commonly following vaccination but even more rarely in a paraneoplastic context. Herein, we will report a patient presenting with subacute inflammatory myelopathy after a fourth dose of the mRNA COVID-19 vaccine. Concurrently, a diagnosis of MOGAD was made with a metastatic abdominal seminoma. The patient was acutely treated with high-dose steroids followed by plasma exchange therapy and was subsequently started on a chemotherapy regimen for the underlying germ cell tumor. The patient had a complete resolution of neurological symptoms upon the last follow-up. Overall, 72 cases of COVID-19 vaccination associated with MOGAD were analyzed (median age at onset 39 years old; female to male ratio = 1.2:1). All cases occurred in adults except for an adolescent, with the majority occurring after vaccination with ChAdOx nCoV-19 (87%), and an average temporal profile between vaccination and symptom onset of 19 days. There were no reported cases after the third or fourth doses, and most patients were diagnosed with new-onset MOGAD after their first vaccine (76%). Although COVID-19 vaccination could be a potential causality, there are significant discrepancies between the reported cases and this patient, alongside the unlikely causality assessment obtained with the Bradford Hill criteria. Vaccination could unmask potential pre-existing autoimmune diseases, such as in this patient, where myelopathy was most likely part of a paraneoplastic syndrome associated with a newly diagnosed seminoma.