Neurohospitalist最新文献

Background and Purpose: Telestroke improves access to acute ischemic stroke (AIS) expertise, aids in decision-making, and reduces interhospital transfers. Few studies have examined subacute inpatient telestroke services, which focus on inpatient stroke workup and management. Methods: In this retrospective cohort study of patients with emergency department (ED) diagnosis of AIS from 10/2021-6/2024, we sought to determine the impact of a novel subacute telestroke program on ED transfer rates at participating hospitals. For intervention sites (that implemented the subacute teleconsult program), the period prior to subacute consult "go-live" date was considered the pre-implementation period. Control sites (without the subacute program) were considered preimplementation prior to 5/22/2023 (when approximately half of intervention sites had initiated the subacute program). Logistic regression with generalized estimating equations evaluated the association between implementation time-period and odds of ED transfer in intervention and control sites, adjusting for age, NIHSS, sex, race, and an intervention by time-period interaction term. Results: 1266 patients met eligibility criteria (N = 544 patients from 11 control sites and N = 722 patients from 11 intervention sites). The ED transfer rate was lower within intervention sites post-implementation (pre: 25.7% to post: 22.5%) and higher in control sites (pre: 25.9% to post: 27.1%). These comparisons were statistically nonsignificant in the multivariable analysis. Conclusions: There was a reduction in interhospital transfers after implementation of a subacute telestroke consultation service, but results were nonsignificant in adjusted models. Future analyses should evaluate whether receipt of a subacute telestroke encounter at the patient-level is associated with reduced interhospital transfer for stroke.

The claustrum sign, marked by increased MRI signal intensity of the claustrum, is an increasingly recognized imaging finding associated with new-onset refractory status epilepticus (NORSE), and may be associated with a more refractory disease course and worse outcomes. We present a 42-year old male patient who developed NORSE refractory to several treatments including immunotherapy, with MRI demonstrating the claustrum sign early in his disease course. We aim to highlight this sign as an important feature of NORSE, which could alert clinicians to the diagnosis, prompting more extensive workup and aggressive treatment earlier on.

New-onset refractory status epilepticus (NORSE) is one of the most severe neurological manifestations of status epilepticus. The etiology is unknown in about 50% cases, as so-called cryptogenic NORSE (C-NORSE). We report a case with emergence of atypical lymphocytes just before C-NORSE. A 25-year-old woman with no significant medical history presented to our department with a 4-day history of headache and fever. Neurological examination and cerebrospinal fluid tests yielded normal results, but atypical lymphocytes were observed in the serum. Two days later, she was admitted to our emergency department in a comatose state, and subsequently developed convulsive refractory status epilepticus. The etiology remained unknown despite an extensive diagnostic work-up, so C-NORSE was diagnosed. Seizures were controlled with immunotherapies including corticosteroids, intravenous immunoglobulins, rituximab, tocilizumab, and administration of 4 antiseizure medications. The etiology of atypical lymphocytes involves hypercytokinemia similar to NORSE, and clarification of the emergence of atypical lymphocytes just before the onset of NORSE could contribute to the understanding of the pathophysiology of NORSE.

Altered mental status is a common chief complaint among patients who visit the emergency department. Encephalitis is one of many disease processes that can lead to altered mental status. We present a unique case of a 52-year-old man presenting in the emergency department with aggressive behavior and altered mental status. CT imaging revealed a newly-discovered renal cell cancer, as well as CSF analysis highly suggestive of anti-GAD-associated encephalitis. Patient was successfully treated with steroids and plasmapheresis to achieve significant clinical improvement. To our knowledge, this is the first reported case of anti-GAD paraneoplastic encephalitis in the setting of renal cell cancer that initially presented with aggressive behavior and altered mental status.

Acute hemorrhagic leukoencephalitis (AHLE) is a rare but fulminant variant of acute disseminated encephalomyelitis, an uncommon immune-mediated demyelinating disorder. We report a case of AHLE in a 27-year-old pregnant woman who presented with acute onset of fever, aphasia, and a generalized seizure, followed by rapid neurological deterioration. The hallmark neuroimaging findings made the prompt diagnosis. The patient responded dramatically to high-dose corticosteroid therapy, with full neurological recovery. She subsequently delivered a healthy full-term infant and remained asymptomatic at one-year follow-up.

Results: We report a case of central pontine hemorrhage presenting with pinpoint pupils and a unique "onion-skin" pattern of facial sensory loss. Conclusions: This distribution of sensory loss reflects selective rostral involvement of the spinal trigeminal nucleus, in contrast to the segmental distribution seen with trigeminal nerve involvement. These findings may serve as a localizing sign of pontine pathology on clinical examination.

Background: Spontaneous intracranial hypotension (SIH) results from cerebrospinal fluid (CSF) leakage due to spinal dural tears or CSF-venous fistulas. Orthostatic headache is the hallmark presentation, though severe downward displacement of the brainstem may lead to altered consciousness or coma. Definitive treatments include targeted epidural blood patches, venous embolization, or surgical repair.

Methods: This article reviews the role of the Trendelenburg position as a temporizing measure in the acute management of SIH. We describe the correct technique, physiologic rationale, and practical considerations for its application, with attention to both therapeutic and diagnostic utility.

Discussion: Positioning the patient with the feet elevated above the head can reduce brain sag and provide short-term symptomatic relief while awaiting definitive treatment. Although the Trendelenburg position is widely used in practice, supporting evidence remains limited, and clinicians must be aware of its benefits, indications, and inherent limitations. Its appropriate application may assist in stabilizing patients with acute or severe SIH, particularly those with impaired consciousness, until more definitive interventions are pursued.

Introduction: Neurenteric cysts are rare congenital lesions of endodermal origin that typically present with slowly progressive myelopathy. Accounting for less than 2% of all spinal tumors, they most often occur in the cervical and upper thoracic spine. Acute neurological deterioration due to a neurenteric cyst is uncommon and represents a clinical emergency.

Case presentation: We describe an 18-year-old woman with no prior medical history who developed sudden-onset neck pain, rapidly progressive quadriparesis, and respiratory compromise. Neurological examination revealed upper motor neuron signs with a C4 sensory level. Cervical magnetic resonance imaging showed a ventral intradural extramedullary cystic lesion at the C2-C3 level, compressing the spinal cord and producing cord edema. Emergent posterior C2-C3 laminectomy was performed, and a tense mucin-filled cyst was completely excised. Histopathology demonstrated a columnar mucinous epithelium with goblet cells, confirming the diagnosis of a neurenteric cyst. Postoperatively, the patient exhibited substantial neurological recovery, regaining independent ambulation within three months. Follow-up imaging at six months showed no recurrence.

Discussion: This case underscores two important lessons. First, although neurenteric cysts are classically indolent, they may present with abrupt, life-threatening neurological decline, even in the absence of associated congenital vertebral anomalies. Second, prompt surgical decompression with gross total resection remains the cornerstone of management, offering excellent potential for recovery. Given the risk of recurrence, radiological surveillance is warranted. This report adds to the limited literature on cervical neurenteric cysts with hyperacute presentations and emphasizes the need for early recognition and timely intervention to optimize outcomes.