Neurohospitalist最新文献

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.

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.