Neurohospitalist最新文献

Subacute, painful weakness is a common problem encountered by neurologists and can be associated with systemic symptoms. The patient presented with 6 weeks of progressive neuropathic pain followed by sensory changes and distal-predominant weakness. This case reviews the broad differential for such a presentation and a comprehensive, stepwise approach to diagnosis. Particular attention is paid to the potentially treatable polyradiculoneuropathies, including more recently recognized immune-mediated etiologies. Through this stepwise approach, we review how a definitive diagnosis was made.

A neurology resident reflects on a pivotal moment during the assessment of an elderly patient, when attention shifts unexpectedly to the patient's caregiver, his wife. The resident quickly recognizes a neurological deficit that could potentially be treated. Sensing the urgency, the resident rushes her to the emergency department, where immediate treatment enables the caregiver to regain her ability to continue caring for her husband. This experience teaches the resident a profound lesson about the importance of vigilance not only toward primary patients but also toward those quietly supporting them. It highlights how timely intervention can preserve the connections that bind families, emphasizing the role of healthcare providers in maintaining these bonds.

Deterioration of a patient's state of consciousness is among the most concerning signs encountered in clinical practice. The evaluation of this finding carries a broad initial differential diagnosis and must account for any relevant medical history. We describe the case of a 41-year-old male with known retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations (RVCL-S) who presented with progressive mental status decline and acute onset intractable headache. Head computed tomography (CT) revealed extensive vasogenic edema, resulting in right to left shift of 11 millimeters at the level of the lateral ventricles, with associated uncal and subfalcine herniation. He was treated with a 5-day course of methylprednisolone, leading to resolution of his lethargy and headache. Follow up neuroimaging with magnetic resonance (MRI) brain demonstrated interval improvement with the midline shift reduced to 3 millimeters after completion of high dose corticosteroids. Neurosurgical intervention was considered, but ultimately not required given his improvement. This case describes the management of life-threatening cerebral edema as a complication of RVCL-S disease progression. Due to the rarity of this disease, there are no standardized guidelines for treatment and the care for such patients relies on expert opinion, case studies, and extrapolation of principles learned from related conditions. Our intention is that the reporting of this case will contribute to the limited body of literature and aid those affected by this condition.

Background and purpose: High quality clinical documentation is a fundamental skill for practicing physicians and important for quality improvement. However, documentation and coding are rarely integrated into medical education curricula and there is a lack of standard neurology curriculum on this topic. We developed and evaluated a teaching session on clinical documentation for neurology resident physicians.

Methods: The education consisted of a didactic session designed by a neurologist with content about risk-adjusted mortality, clinical documentation integrity (CDI), impact of documentation on patients, and neurology-specific documentation guidance. A pre-post survey design was used to compare baseline and post-intervention self-reported knowledge and attitudes.

Results: 61 responses were collected (37 pre- and 24 post-intervention). Residents had increased understanding of the impact of documentation on quality metrics (P = 0.004), risk-adjusted mortality (P < 0.0001), and impact on patients (P = 0.02). Attitude towards CDI education improved significantly (P = 0.0016), as well as agreement that CDI is important to resident physicians (P = 0.003). The portion of residents who agreed training on CDI is useful and valuable increased significantly (P = 0.004). 92% agreed this curriculum was useful, and 96% agreed they understood the role of CDI better after the session.

Conclusions: In this study of a teaching session for neurology residents on clinical documentation, we found this format of teaching was well-received and highly effective in improving resident attitudes and self-reported knowledge.

Cryptococcal meningitis is a leading cause of morbidity and mortality in patients infected with human immunodeficiency virus. In over 90% of cases, it occurs at CD4 T lymphocyte (CD4) cell counts of less than 100 cells/mm³. Cryptococcomas are rare granulomatous lesions that can occur in disseminated central nervous system cryptococcal infection, primarily in immunocompetent hosts. Here we report a case of disseminated cryptococcal meningitis with numerous cryptococcomas mimicking metastases in a patient with HIV and a CD4 count of 115. The patient's serum and cerebrospinal fluid (CSF) cryptococcal antigen, CSF cryptococcal polymerase chain reaction, and serum and CSF cryptococcal cultures were all negative. Brain biopsy pathology confirmed the diagnosis. In this paper, we highlight the importance of early cerebral biopsy in the diagnosis and management of cryptococcoma.

The Neurohospitalist Core Competencies comprise a set of competency-based learning objectives that encapsulate the knowledge, skills, and attitudes of neurohospitalitists who specialize in the care of hospitalized patients with neurologic conditions. These competencies serve to characterize the rapidly expanding field of neurohospitalist medicine. The 27 chapters are divided into 3 sections entitled: neurological conditions, clinical interventions and interpretation of ancillary studies, and neurohospitalist role in the healthcare system. Each individual learning objective in the chapters describes a specific concept with an action verb to illustrate the behavior that the neurohospitalist exhibits. The individual neurohospitalist may not exhibit mastery in each of the topics included as individual practices vary in scope and practice pattern. A few examples of how the complete set of competencies may be used include in the creation of curricula for neurohospitalist fellowships, to assist in defining the scope of practice of neurohospitalists for administrative leaders of hospitals and departments, and in influencing the direction of further research and quality improvement in the field.

Brain metastases in prostate cancer are rare (<2% of cases). In magnetic resonance imaging, nearly all brain metastases exhibit contrast-enhancement, which may be affected by the time elapsed since the administration of the contrast agent. We discuss a case where the brain metastases in a patient with prostate cancer do not show a clear contrast-enhancement on magnetic resonance imaging using a standard brain metastases protocol. It also emphasizes the usefulness of delayed imaging in identifying blood-brain barrier damage. We present the case of a 69-year-old man diagnosed with prostate adenocarcinoma, currently in castration-resistant phase (last value of serum prostate-specific antigen: 45.1 ng/mL) with bone, mediastinal and inguinal lymph nodes, pulmonary, and hepatic metastases. In a contrast-enhanced whole-body computed tomography examination, the appearance of intra-axial brain lesions suspicious for metastases was documented. The subsequent contrast-enhanced brain magnetic resonance imaging showed the presence of 5 intra-axial lesions consistent with brain metastases. These lesions exhibited hyperintense signals in T2-fluid-attenuated inversion recovery images; after contrast agent administration, a ring-like contrast-enhancement was more clearly visible in T1-weighted images acquired later (about 15 minutes after contrast agent administration) than in those acquired earlier (about 5-7 minutes after contrast agent administration). In conclusion, for oncological subjects with multiple brain lesions lacking obvious contrast-enhancement using a standard magnetic resonance imaging protocol, we suggest acquiring late images. These might allow for the detection of even minimal post-contrast impregnation, improving confidence in the diagnosis of brain metastases.

Background: Moyamoya disease (MMD) is a rare pathological state characterized by progressive stenosis of the terminal portion of the internal carotid arteries (ICA). Complications include both ischemic and hemorrhagic strokes, for which there is no curative treatment for MMD. Early diagnosis with surgical intervention is vital for there is no definitive treatment. Due to the bimodal age distribution, moyamoya should be considered for patients presenting with stroke and supraclinoid ICA vasculopathy.

Case: We present a case of a 23-year-old female who presented with left arm weakness and sudden onset thunderclap headache. Upon further questioning, it was revealed that the patient had started an estrogen-containing birth control two weeks prior to presentation. Neuroimaging at our tertiary care center demonstrated simultaneous ischemic and hemorrhagic strokes in the bilateral hemispheres associated with vasculopathy seen in both invasive and noninvasive cerebrovascular imaging. She was diagnosed with idiopathic moyamoya disease since her serum and cerebrospinal fluid studies did not reveal any obvious precipitators to suggest moyamoya syndrome (MMS).

Conclusion: There were no obvious precipitating factors identified in the extensive workup for this patient. Therefore, further secondary prevention is difficult for this otherwise young and healthy individual. While there is data to support the use of antiplatelet medications for the prevention of ischemic stroke secondary to intracranial atherosclerotic disease, there are no clear guidelines for the treatment of MMD that simultaneously causes ischemic and hemorrhagic stroke. Further research on the pathophysiology and treatment modalities for MMD are needed to guide clinicians in treating this complex disease.

With increased patient volumes and complexity, stroke occurrence in hospitalized patients has become relatively more common. The process of activating a code stroke in-hospital differs in many institutions. An emergency team-based response to inpatient acute code stroke is warranted, with many protocols modeled similarly to the cardiac arrest response. However, several studies have demonstrated delays in recognition and management of acute stroke in-hospital as compared to those arriving directly to the emergency department (ED). Furthermore, there are several shared challenges with code stroke resuscitation in the emergency department and the ward, which include the assembly of ad hoc teams and requirement of access to urgent imaging. Delays in activating in-hospital code stroke contributes to increased morbidity, mortality, prolonged hospitalization, and associated health care costs. In the following commentary, we discuss the current landscape of acute in-hospital code stroke protocols, review the differences in neurologic outcomes between inpatient vs ED/out-of-hospital code stroke patients, and propose future directions for in-hospital code stroke paradigms for improved patient outcomes and quality of care.

Background and purpose: Neurohospitalists specialize in the care of hospitalized patients with neurological conditions. As the neurohospitalist model of patient care has grown rapidly and in diverse ways, there has been increasing demand for a formal definition of the field, particularly to support curriculum development for learners at multiple levels.

Methods: The Neurohospitalist Society (NHS) formed a Core Competencies Committee in 2021. This committee defined the scope of the Neurohospitalist Core Competencies and organized the competency topics into chapters. This chapter list was approved by the members of the NHS. An open invitation was made to the general membership of the NHS to write chapters on a first-come, first-served basis, using a standardized chapter template developed by the Committee. A three-step editing process was completed, with members of the Committee serving as editors. A dissemination strategy was designed, including drafting of 2 manuscripts (the Core Competencies themselves, and this accompanying manuscript) and outreach to the general membership of the NHS.

Results: The Neurohospitalist Core Competencies include 27 chapters divided into 3 sections: neurological conditions; clinical interventions and interpretations of ancillary studies; and neurohospitalist role in the health care system. The complete version of the Neurohospitalist Core Competencies is published as a separate manuscript in this issue of The Neurohospitalist.

Conclusions: The creation of the Neurohospitalist Core Competencies was a multi-year initiative intended to support practicing neurohospitalists, trainees interested in pursuing careers in the field, medical education leaders, and administrative leaders of hospitals and departments.