Neurohospitalist最新文献

Background: Heavy alcohol use is associated with an increased risk of Intracerebral Hemorrhage (ICH), but the relationship with lesser amounts of alcohol is uncertain. Tribals in East India have a higher prevalence of alcohol abuse. We assessed the dose-risk relationship between alcohol consumption and ICH and evaluated the intra-population variations of this risk.

Methods: In this case-control study, we recruited 510 patients with ICH. Cases were matched 1:1 with ICH-free controls. Alcohol consumption patterns were designated into groups - none, rare, moderate, intermediate, and heavy. The no-alcohol consumption category was used as reference to determine ICH risk.

Results: Rare and moderate alcohol consumption conferred a decreased risk of ICH (OR = 0.35, P value <0.001 and OR = 0.58, P value 0.008 respectively). Patients with heavy alcohol use were at a significantly higher risk (OR = 1.65, P value = 0.027). Subgroup analysis revealed similar risk profiles for rare and moderate consumption in both lobar and non-lobar ICH, whereas heavy alcohol conferred an increased risk only for non-lobar ICH. Heavy alcohol consumption was also associated with risk of ICH in tribals (OR = 3.24. P value = 0.04).

Conclusion: Rare and moderate alcohol consumption may have a protective effect on ICH risk whereas heavy alcohol use is associated with an increased risk, Further, tribal populations have an increased ICH risk with heavy alcohol use with no decrease in risk with rare or moderate use. This highlights the need for culturally tailored prevention strategies for these communities.

Introduction: New Onset Refractory Status Epilepticus (NORSE) occurs without an acute structural, toxic, or metabolic cause in individuals without known epilepsy or a related neurological disease. In about 50% of cases, NORSE is attributed to autoimmune or viral encephalitis; in the rest, it remains cryptogenic, posing significant treatment challenges and high risks of mortality and long-term neurological issues. Standard management often involves multiple antiseizure medications, and immunosuppressive therapies used even when an autoimmune cause is unproven. Case Description: We report a 23-year-old woman with cryptogenic NORSE resistant to multiple antiseizure medications, intravenous anesthetics, and immunosuppression, requiring a 5-month barbiturate-induced coma. Attempts to reduce anesthetics triggered recurrent super-refractory status epilepticus. Extensive working up including neuroimaging, cerebrospinal fluid, and autoimmune testing revealed no clear etiology. High-dose steroids, IVIG, plasmapheresis, rituximab, tocilizumab, and anakinra were ineffective. An FDA authorization for emergency single-patient IND (eIND) approval allowed treatment with IV ganaxolone, a GABA_A receptor modulator, which was used alongside electroconvulsive therapy. Nine days after initiation of ganaxolone and 13 days after ECT was started, pentobarbital was successfully tapered, and seizures ceased. Consciousness and near-normal language function returned gradually, with residual cognitive deficits. After an 8-month hospitalization, she was discharged to inpatient rehabilitation and subsequently home. At 6 months post-discharge, her Glasgow Outcome Scale-Extended Score was 7.

Background: Patients with spontaneous intracranial hemorrhage (ICH) who present to non-tertiary care centers are often transferred to a facility with neurosurgical expertise without consideration of the likelihood of surgical intervention. At our Comprehensive Stroke Center (CSC), a minority of patients transferred for neurosurgical evaluation undergo interventions putting a strain on hospital resources. This study aimed to (1) quantify the frequency of neurosurgical intervention in ICH patients transferred to our hospital and, (2) to develop a tool to aid in transfer decisions.

Methods: Using an IRB-approved retrospective cohort study design, we identified all spontaneous ICH patients transferred to our CSC between January 1, 2016, and May 31, 2023. All patients were reviewed to ensure a primary diagnosis of non-traumatic supratentorial ICH. Odds ratios were calculated using a logistic regression model to identify factors predictive of neurosurgery which were weighted by strength of association. Internal validation was then performed.

Results: Of the 496 participants included in the final dataset, 78 (15.7%) underwent neurosurgical intervention. Age, Glasgow Coma Scale, ICH volume, and intraventricular extension were the greatest predictors of neurosurgery. These factors were used to create the Likelihood of Neurosurgery Score (LoNS), a weighted score used to inform transfer decisions. The score performed well on calibration and discrimination tests.

Conclusion: The LoNS is a new tool to identify ICH patients unlikely to be neurosurgical candidates who could be safely managed at the local level rather than urgently transferred to a tertiary care center. Prospective validation is needed.

Objective: To describe a case of delayed onset multiple cranial neuropathies as a manifestation of neurotoxicity after chimeric antigen receptor T-cell (CAR-T) therapy for multiple myeloma. While ICANS following CAR-T is a well-reported complication, it classically presents with encephalopathy, seizures, dysphasia, tremors, headache, and cerebral edema. Isolated unilateral facial neuropathies secondary to CAR-T neurotoxicity have been described, but progressive multiple cranial neuropathies have not. Herein, a 75-year-old male presented with left facial nerve palsy 19 days after initiating CAR-T therapy for multiple myeloma. Contrasted brain MRI showed contralateral right facial nerve enhancement, and his left facial palsy was treated with steroids and valacyclovir for 7 days. The facial palsy persisted and progressed to involve bilateral facial nerves and left cranial nerve VI by 31 days post-CAR-T. Specifically, his exam showed impaired abduction of left eye and nearly absent facial movement. Repeat contrasted MRI brain showed mild enhancement of bilateral facial nerves. Extensive serum and CSF testing was unremarkable. Initial treatment with oral steroids for 7 days was ineffective. Concern regarding the impact of steroids on CAR-T efficacy influenced treatment dose and duration. Anakinra was considered but not given. Subsequent treatment with intravenous high dose steroids, followed by a prolonged prednisone taper, led to resolution of CN VI palsy at 2.5 months from onset (2 weeks after completed therapy), and moderate improvement of bilateral facial palsy 5.5 months from onset (3.5 months after completed therapy). CAR-T neurotoxicity can present with progressive multiple cranial neuropathies. The best treatment of these cases is unknown; however, this patient improved in the context of corticosteroids and facial rehabilitation over a prolonged period of follow-up.

Objectives: Anemia has been associated with cerebral venous thrombosis (CVT) and poor outcomes. There have been no Indian studies in this regard. We studied the frequency and type of anemia, and CVT outcomes at 6 months.

Methods: In this ambispective, observational study imaging confirmed CVT patients were enrolled. Anemia was defined by WHO criteria: in men hemoglobin <13 g/dL, non-pregnant women hemoglobin <12 g/dL and pregnant women hemoglobin <11 g/dL. Mortality and poor outcome ie, modified Rankin scale (mRS) score of 3-6 at 6-month were the outcomes. Association between admission anemia and outcome was examined using binary logistic regression after adjusting for potential confounders-namely, age, sex, poor GCS, alcohol, smoking, and involvement of multiple sinuses.

Results: Data of 203 CVT patients (94 retrospective and 109 prospective) were analysed. Anemia was present in 96/203 (47%) patients, microcytic anemia being most frequent type (47/96, 49%) based on erythrocyte morphology. Severe anemia comprised 24% (23/96) of the patients with anemia. As per iron studies, 61/96 (64%) anemia patients had iron-deficiency anemia. At 6-month poor outcome was present in 38% vs 23% (P = 0.02), mortality was 34% vs 20% (P = 0.03) in anemic and non-anemic group respectively. After adjustment for confounders anemia was independently associated with increased risk of poor outcome (aOR 4.3; 95% CI 1.3-13.9) and mortality (aOR 5.2; 95% CI 1.4-19.3).

Conclusion: At admission, anemia is present in almost half CVT patients and is associated with increased risk of poor outcome and higher mortality.

Isolated bilateral vertical gaze palsy is an unusual presentation in acute settings. It is usually accompanied by subtle signs that can lead to precise anatomic localization. This case is notable for the rare co-occurrence of bilateral vertical gaze palsy, Collier's sign, and contralesional pseudo-abducens paresis with a unilateral dorsomedial thalamic infarct, highlighting the complexity of vertical gaze and convergence pathways.

Background: Ischemic stroke due to hypereosinophilic syndromes (HES) is a rare but severe neurological emergency. HES may be secondary to infections, autoimmune conditions, severe allergic reactions, or hematologic disorders. Among these, clonal forms associated with myeloproliferation are particularly aggressive and can lead to recurrent cerebral infarctions with high mortality. Purpose: We report the case of an elderly patient with newly diagnosed extreme eosinophilia who developed multiple progressive strokes and ultimately died despite early and aggressive treatment. Conclusions: This case emphasizes the importance of rapid recognition, highlights the unique radiological signature of border-zone infarctions in this context, and raises concern about the critical role of granulocytes in cerebral microcirculation. It also underscores that partial reduction of eosinophils may be insufficient for stroke prevention and that full normalization may be necessary.

Background: Electroencephalography (EEG) is increasingly used in intensive care units (ICUs), primarily for seizure detection. However, the complex clinical context of critically ill patients and the dynamic ICU environment can complicate interpretation. Purpose: To highlight common pitfalls in ICU EEG interpretation and strategies to distinguish epileptic seizures from mimics. Research Design: Retrospective case series. Study Sample: Five ICU patients undergoing continuous video EEG (cvEEG) for altered mental status, status epilepticus, or paroxysmal events, with underlying conditions including malignancy, autoimmune encephalitis, neuromodulation therapy, and drug-resistant epilepsy. Results: Physiological artifacts, such as non-epileptic rhythmic movements, and device-related artifacts (e.g., pacemakers, ventilators) can mimic epileptic seizures. Plateau waves from elevated intracranial pressure may produce deficits resembling epileptic seizures. Accurate differentiation requires attention to clinical context, EEG features, and video correlation. Maintaining a broad differential and avoiding diagnostic anchoring are also essential to prevent misdiagnosis and unnecessary antiseizure medication therapy. Conclusions: ICU EEG interpretation is challenged by artifacts and non-epileptic movements that mimic epileptic seizures. Awareness of these issues, along with a thoughtful, multidisciplinary approach, is critical for improving diagnostic accuracy and optimizing patient outcomes during cvEEG monitoring.