Neurohospitalist最新文献

We read with great interest the case report by Murray et al describing transverse myelitis associated with helminthic infection. While intriguing, several aspects of the diagnostic workup and clinical interpretation warrant further clarification. Pain, treatment response, and cerebrospinal fluid (CSF) and radiological follow-up findings suggest that a demyelinating centrale nervous system (CNS) disorder, such as MOG antibody-associated disease, multiple sclerosis, or neuromyelitis optica spectrum disorders (NMOSD), could represent a plausible alternative explanation. Additional investigations, including antibody testing and serial magnetic resonance imaging (MRI), would have strengthened the diagnostic conclusions. We argue that a more comprehensive assessment is essential to avoid premature attribution of the clinical picture solely to helminthic infection.

Background: Horizontal conjugate eye deviation (HCED) is typically associated with supratentorial strokes affecting the frontal eye fields and associated pathways. However, a rare form of HCED, ocular ipsipulsion, is caused by a lateral medullary lesion. The presumed mechanism involves disruption of decussating olivocerebellar fibers, leading to an imbalance in vestibular nuclei activity. Purpose: To report a case of isolated ocular ipsipulsion as a diagnostic clue to central vertigo. Research Design: Case report. Study Sample: An 82-year-old man with a right lateral medullary infarction. Data Collection: Neurological examination and brain magnetic resonance imaging (MRI) were performed. Ocular findings were documented through bedside observation and video recording. Results: The patient presented with acute vertigo and HCED consistent with ocular ipsipulsion, without other neurological signs. On brain MRI a right lateral medullary infarction was observed. Conclusions: This oculomotor dysfunction can be the only clue in the neurological examination to suspect a central vertigo. Clinicians should be aware of this sign and include its assessment in the bedside evaluation of acute vertigo in the emergency setting if a central cause is suspected.

Background: Postpartum subarachnoid hemorrhage caused by aneurysm rupture is a rare but potentially life-threatening complication that can mimic a benign postpartum headache, especially after neuraxial anesthesia.

Case report: We describe a 40-year-old woman who developed a severe headache, predominantly located in the occipital and posterior neck region, following cesarean section under spinal anesthesia. Initially presumed to be post-dural puncture headache, her condition deteriorated by postoperative day 5, with coma and seizures. Cranial computed tomography revealed diffuse subarachnoid and intraventricular hemorrhage. Vascular imaging showed a dissecting aneurysm of the right vertebral artery (V4 segment), with the posterior inferior cerebellar artery arising from the aneurysm dome. She underwent endovascular coiling with parent vessel sacrifice. Her recovery was favorable, with only mild cerebellar ataxia at discharge. At the 3-year follow-up, she was neurologically intact.

Discussion: This case underscores the importance of considering aneurysmal subarachnoid hemorrhage in postpartum patients with atypical or worsening headache following neuraxial anesthesia. Early neuroimaging and timely intervention can lead to excellent outcomes.

Miller Fisher Syndrome (MFS) is a rare neurological disorder characterized by ataxia, areflexia, and ophthalmoplegia. It is considered a variant of Guillain-Barré syndrome (GBS). Infections frequently precede the onset of MFS. A 44-year-old patient was referred to our Neurology Department due to rapidly progressive bilateral limb ataxia, areflexia, and external ophthalmoplegia following acute tonsillitis with fever and oral mucosal lesions. Initial extensive diagnostic work-up, including immunoglobulin M (IgM) serum antibodies against cytomegalovirus (CMV), was negative. However, due to clinical suspicion, anti-CMV IgM was tested again and subsequently found to be positive. Interestingly, antibodies against Q1B ganglioside, which are specific for MFS, were also negative. Our patient gradually improved after intravenous immunoglobulin administration and symptomatic treatment. No underlying cause of immunocompromise was identified. This case underscores the importance of persistent testing for CMV antibodies in immunocompetent patients, even in rare cases of GBS like MFS, to ensure accurate diagnosis and optimize treatment plans.

Background and purpose: Examination of the ocular fundus is part of the neurologic examination. However, bedside ophthalmoscopy is rarely performed, especially in emergency departments (EDs), with risk of delayed diagnoses and inappropriate triage. Our goal was to determine how often funduscopic examination using non-mydriatic ocular fundus photography combined with optical coherence tomography (NMPF-OCT) is possible and useful in a consecutive cohort of patients with neurologic/neurosurgical disorders evaluated in a general ED.

Methods: This was a quality improvement project, prospective over 16 consecutive days/nights. NMFP-OCT was ordered for all patients presenting to our ED with any neurologic/neurosurgical disorders. Demographic information, neurologic diagnoses, presence of headache and NMFP-OCT findings were collected.

Results: Over 1838 ED visits, 448 (24.4%) patients reported neurologic complaints, including headache, or a history of neurologic disorders, of which 246 (54.9%) received NMFP-OCT imaging. Papilledema was ruled out for 233/246 patients with images, and abnormal ocular fundus findings were found in 29/246 (11.8%) patients, 22/29 with acute neurological complaints, 3/29 with isolated headache, and 4/29 with a history of neurologic/neurosurgical disorders. Findings included papilledema (9), other optic disc edema (3), optic atrophy (11), retinopathies (4), and other (2).

Conclusion: NMFP-OCT obtained in the ED in neurologic/neurosurgical patients allowed for rapid and reliable diagnosis of ocular fundus pathology in 11.8% of patients, confirming that NMFP-OCT is useful in patients with neurologic/neurosurgical disorders. However, 43% patients could not have NMFP-OCT, many due to illness severity, reinforcing the need for in-person funduscopic examination in some neurology/neurosurgery patients unable to have imaging.

Subacute combined degeneration (SCD) is characterized by demyelination primarily affecting the dorsal column and lateral corticospinal tracts. It typically presents with paresthesia in the feet and progresses to involve the upper extremities. SCD is commonly associated with nutritional deficiencies, particularly deficiencies of vitamin B12, folate, or copper. Neurological disorders solely caused by isolated folate deficiency are uncommon. Classic presentations of folate deficiency include fatigue, lethargy, glossitis, diarrhea, and the gradual development of megaloblastic anemia. Early SCD diagnosis and treatment, even in the absence of hematological signs, are imperative to prevent irreversible neurological deficits and achieve favorable outcomes. We present a patient with IgG4-related disease who developed subacute sensory ataxia and generalized hyperreflexia. She was eventually diagnosed with SCD, which was attributed to isolated folate deficiency caused by critical illness-related malnutrition and concomitant co-trimoxazole use. Her clinical and neurological examination findings improved at the subsequent 2-week follow-up after effective treatment. Finally, she was able to walk and run independently. This case emphasizes the importance of early recognition of this rare presentation and prompt treatment, which can significantly contribute to better neurological outcomes.

Background: Telestroke emergency department (ED) workflow emulates that of in-person care, yet limitations of the virtual interaction may require accommodations. The optimal sequence of non-contrast head CT, cerebral CT angiogram, and decision to infuse IV thrombolytic is not defined for telestroke.

Methods: In this twenty-two-hospital multicenter retrospective study between 1/1/2024-12/31/2024, we characterized timing of ED CT angiograms, either bundled with the non-contrast head CT or non-bundled and performed after the IV-thrombolytic decision. The primary outcome was effect of bundling on door to needle time (DTN) when directed by telestroke. Timing of CT scans was determined by time stamps of scout images.

Results: In total, 5704 patients were included, with a median age of 65 years (Interquartile range, IQR 58-77) and NIHSS 8 (IQR 6-13). There were 4518 patients in the bundled group (n = 12 hospitals), with time from non-contrast CT to CTA of median 2 min (IQR 0-6 min; vs non-bundled (n = 10 hospitals): 7, 4-15 min; P = .0001). DTN was not statistically different between the groups, bundled vs not: median 47 min (IQR, 35-62 min) vs 54 min (IQR, 41-67 min, P = .21). Door in door out (DIDO) times also were unchanged (169, 117-254 vs 175, 123-247 min; P = .56). These findings, although showing no statistical difference, may have significance for clinical workflows and were consistent with the results of validation analyses conducted on individual patients.

Conclusions: Bundling non-contrast head CT with the CT angiogram before thrombolytic decision did not delay DTN times, trended to clinically improve times, and may be relevant for telestroke ED workflows.

Background: Transient ischemic attack (TIA) carries a high risk of stroke, necessitating immediate evaluation and risk modification. Patients in high-social determinants of health-burden communities often face barriers to rapid outpatient care, while inpatient admission can be resource-intensive and burdensome. We describe outcomes from a rapid TIA inpatient workflow (Rapid TIA) implemented at an urban academic medical center.

Methods: A retrospective single institution observational study of 411 consecutive patients admitted for TIA over 4 years in the Bronx, NY. Rapid TIA had 3 phases: (1) initial neurologic evaluation, (2) hospital admission and expedited implementation of care, and (3) transition to outpatient specialty care. We compared 6 variables related to care delivery, as well as long-term outcomes, in the pre-implementation vs post-implementation groups.

Results: The Rapid TIA program was associated with a significant improvement in overall care delivery measured using a composite process measure score from 3.2 (±1.1) pre-implementation to 3.8 (±1.1) post-implementation (OR 1.63, 95% CI: 1.35, 1.98, P = 0.001). Combined 1 year readmission rates for stroke/TIA, MI, and major bleeding events decreased from 15% (n = 28) in the pre-implementation group to 7% (n = 15) post-implementation (95% CI: 0.19, 0.74, P = 0.004).

Conclusions: Our study demonstrates that a rapid-inpatient TIA management pathway can significantly improve quality care and reduce readmissions. Rapid TIA may serve as a model for TIA care delivery in other underserved communities.

Background: Hyperhomocysteinemia is a known risk factor for stroke and neuropathy, though their coexistence is rare. Case Description: A 43-year-old male with chronic myeloid leukemia developed progressive neuropathy and later suffered an ischemic stroke. Investigations revealed severe hyperhomocysteinemia and vitamin B12 deficiency, likely due to chronic nitrous oxide use, folate supplementation without cobalamin, and malnutrition. Despite B12 supplementation, recurrent strokes led to the identification of a homozygous MTHFR 677C>T mutation. Conclusions: This case underscores the essential need to consider all contributing factors and conduct a comprehensive etiological workup, avoiding a narrow focus on obvious causes.

Rozanolixizumab is a neonatal Fc receptor (FcRn) blocker recently approved for treating generalized myasthenia gravis (gMG), particularly in patients who are anti-AChR or anti-MuSK antibody positive. Although clinical trials have demonstrated a favorable safety profile, rare adverse neurological effects remain underreported. A 36-year-old woman with refractory anti-MuSK-positive generalized myasthenia gravis received an infusion of rozanolixizumab after failing to respond to corticosteroids and azathioprine. 5 days post-infusion, she presented with an acute-onset headache, nausea, vomiting, photophobia, phonophobia, and neck stiffness. Cerebrospinal fluid (CSF) analysis revealed a white blood cell count of 150 cells/μL with 90% neutrophils, normal protein, and glucose levels. The infectious meningitis and encephalitis panel was negative. She was managed supportively, and her symptoms resolved over the following week without antimicrobial therapy. This case suggests a possible link between Rozanolixizumab and aseptic meningitis. Clinicians should be aware of this potential adverse effect and consider drug-induced etiologies in similar clinical scenarios. Early recognition may prevent unnecessary treatment and hospitalizations.