Neurohospitalist最新文献

A 64-year-old female with a history of Subarachnoid Hemorrhage (SAH) of non-aneurysmal origin underwent 4 cerebral Digital Subtraction Angiography (cDSA) studies to investigate the cause of the SAH. All angiograms were unrevealing. Two years and 3 months following her SAH, she presented to the emergency department with ataxia and aphasia. Magnetic Resonance Imaging (MRI) of the brain without contrast showed a right posterior parietal lobe stroke with a watershed appearance and a chronic right cerebellar infarct with encephalomalacia. Repeat cDSA showed stenosis in the right A3 of the Anterior Cerebral Artery (ACA) and right M2 of the Middle Cerebral Artery (MCA) suggesting CNS vasculitis. Known reversible and secondary causes of CNS vasculitis were tested and found to be negative. However, Indirect Immunofluorescence Assay (IFA) testing revealed a high titer of IgG phase II Coxiella indicating acute Q fever. CDC lab findings from 10 years earlier also showed a high titer IgG phase II Coxiella, indicating untreated Q fever prior to the SAH event. A whole-body Positron Emission Tomography (PET) scan was negative for systemic or CNS vasculitis. The patient was treated for Q fever and CNS vasculitis with 1 year of doxycycline and hydroxychloroquine. There was no recurrence of symptoms 15 months after treatment. We conclude that Q fever can present with SAH in addition to CNS vasculitis and stroke.

Background: Tenecteplase (TNK) has been increasingly adopted as an alternative to alteplase (tPA) for ischemic stroke due to its ease of administration and pharmacologic advantages. However, recent studies suggest TNK may be associated with a higher incidence of clot migration, potentially contributing to early neurologic deterioration.

Objective: To describe the incidence and clinical impact of clot migration following TNK administration in acute ischemic stroke patients.

Methods: We retrospectively reviewed consecutive patients treated with TNK at our Comprehensive Stroke Center between May and August 2023. Clot migration was defined as a change in thrombus position without full distal reperfusion. Neurologic deterioration was defined as an NIHSS increase ≥4 or new-onset deficit. All patients underwent pre- and post-TNK vascular imaging.

Results: Among 53 patients treated with TNK, 12 (22.6%) experienced neurological deterioration. Clot migration was identified in 4 patients (8.3%) among those with confirmed vessel occlusion on baseline imaging (n = 48). All exhibited new occlusions in anatomically compatible sites and clinical worsening shortly after TNK. One patient required mechanical thrombectomy; the remaining 3 had distal occlusions or low NIHSS scores. At discharge, two patients had good outcomes (mRS ≤2), and two had poor outcomes (mRS >2).

Conclusion: Clot migration may contribute to early neurologic deterioration following TNK, particularly in posterior circulation strokes. Outcomes appear to depend on final clot location and clinical severity. As TNK becomes more widely used, increased awareness and early vascular imaging are critical for recognizing this phenomenon and guiding management.

Opsoclonus-myoclonus-ataxia syndrome (OMAS) is a rare neurological condition most often diagnosed as a paraneoplastic or parainfectious syndrome. There have been some reports of OMAS in association with West Nile virus (WNV) in the literature, but both treatment and outcomes have been variable. Furthermore, some evidence suggests that patients who are treated earlier in the disease course have better outcomes, both in terms of time to disease remission and long-term symptom relief. Here, we present the case of a healthy 26-year-old patient who suddenly developed tremulousness and weakness of the lower extremities which progressively worsened over the course of 5 days; during this time, the patient developed nausea, gait unsteadiness, and rapid uncontrollable eye movements, leading to his hospital presentation. On hospital day two, the patient was diagnosed with OMAS due to exam findings of rapid, conjugate, saccadic bursts and myoclonic muscle activity, with serum and cerebrospinal fluid studies positive for WNV. Treatment with intravenous steroids and immunoglobulin began immediately afterwards and resulted in rapid improvement by the time of discharge 7 days after treatment was initiated. This case demonstrates the importance of developing broad differential diagnoses for uncommon disease presentations and the importance of treatment timeliness for better outcomes of OMAS. Furthermore, this report shows the need for more systematic studies on OMAS treatment and outcomes, as the current literature is somewhat limited due to the sporadic nature of the disease. Lastly, we highlight the patient's own heartfelt narrative of this illness and his experiences with recovery.

A 54-year-old man presented with coma and left mydriasis due to bilateral thalamic and left paramedian midbrain infarcts. Workup revealed paradoxical embolism from an intrapulmonary shunt. As the patient's mental status improved, complex eye movement abnormalities emerged, including vertical ophthalmoplegia, bilateral ptosis, and right pseudo-abducens palsy. This case highlights the complex and often-overlooked ocular motor neural circuitry in the thalamo-mesencephalic junction.

Background: The association between Parkinson's disease and epilepsy remains unclear. A higher proportion of patients with Parkinson's disease who have experienced seizures had at least one episode of status epilepticus compared to healthy controls. It is crucial to distinguish whether seizures are provoked or unprovoked as this changes the long-term treatment plan and prognosis.

Case presentation: We report a case of new onset seizures refractory to multiple anti-seizure medications in a patient with Parkinson's disease in the context of vitamin B6 deficiency. The seizures started after a recent increase in carbidopa/levodopa dose. Seizures resolved with pyridoxine supplementation. The patient was able to successfully wean off all anti-seizure medications without any further seizures and had incomplete normalization of EEG.

Practical implications: Clinicians should consider vitamin B6 deficiency as an etiology for new-onset refractory seizures in patients with Parkinson's disease on carbidopa/levodopa. Repletion of vitamin B6 can be curative, and patients may ultimately not require long term anti-seizure medications.

Background: Patients with spontaneous non-traumatic intracerebral hemorrhage (ICH) have a heightened risk for venous thrombosis (VTE). The Stroke 2022 Guidelines suggest initiating pharmacologic prophylaxis after hemorrhage stabilization, as measured on repeat imaging within the first 24 hours of admission. However, pharmacologic prophylaxis is underutilized and there remain concerns that initiation of pharmacologic prophylaxis could increase hemorrhage size. This study examines the safety of initiating pharmacologic prophylaxis after hemorrhage stabilization.

Methods: This was a retrospective study of patients discharged with nontraumatic spontaneous ICH. The study population was from Providence Medical Centers in Washington, Oregon, and California. Patients, 18 years or older, presenting to a hospital between January 2018 and December 2021 with a primary diagnosis at discharge of ICH were included.

Results: Among the 228 included, 65.4% (n = 149) received mechanical prophylaxis only and 34.6% (n = 79) received any pharmacologic prophylaxis (with or without mechanical prophylaxis). Of those patients who received any pharmacologic prophylaxis, 55.7% (44) were administered pharmacologic prophylaxis within 48 hours of stabilization. There were no significant differences in age, sex, medical history, hemorrhage type, severity, or mortality in-hospital or at 30 days.

Conclusion: There were no significant differences in VTE events and hemorrhage expansion for spontaneous ICH patients who had pharmacologic with or without mechanical prophylaxis or mechanical only, consistent with previous literature. For patients who received pharmacologic prophylaxis after stabilization, none had hemorrhage expansion; our data support the 2022 guidelines that it is safe to administer pharmacologic prophylaxis after hemorrhage stabilization.

Purpose: Evaluate patient, clinical, and treatment variables impacting mortality in patients with brain abscesses.

Background: Brain abscesses are intraparenchymal infectious foci with significant morbidity and mortality. Management includes antimicrobial therapy +/- surgical intervention, and is dependent on suspected pathogen/source, patient factors, and clinician judgement. Treatment type and duration vary substantially and are often guided by imaging, inflammatory markers, and symptoms.

Methods: 186 patients with brain abscesses admitted at a single health system between 2010 and 2022 were analyzed. Patient demographics, clinical course, diagnostic studies, and abscess treatment were assessed for impact on mortality during admission via univariate and stepwise multivariate nominal logistic regression. Secondary outcomes of surgical drainage were evaluated with univariate and multivariate nominal logistic regression, and survival over time of those who received surgical drainage vs those who did not was evaluated with Kaplan-Meier survival analysis.

Results: 10.7% of patients died during initial admission. Intravenous drug use, deep-seated abscess location, and surgical complication were independently predictive of death during admission. Patients without surgical intervention demonstrated increased likelihood of mortality over time but not during admission. Independent predictors of surgical intervention include lack of ventriculitis, larger abscess diameter, non-hematogenous or -pulmonary source, and mass effect.

Conclusions: These findings suggest surgical intervention is generally avoided when infection is systemic, severe, or with intraventricular abscess rupture. Patients with overt symptoms of brain infection were more likely to receive prompt surgical drainage. In our patient population, surgical drainage in addition to antimicrobial therapy did not independently impact inpatient mortality although did impact overall survival.

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.

Subacute-to-chronic gait instability has a broad differential diagnosis. The neurological exam can help elucidate the localization and suggest an underlying etiology of the symptomatology, which can lead to a more focused diagnostic approach. Two patients are described - 1 with a month of worsening difficulty with ambulation that evolved to bilateral hand discoordination and another with 18 months of progressive difficulty with ambulation that also then progressed to involve her bilateral hands. These cases highlight an approach to gait dysfunction with hand discoordination secondary to sensory ataxia. The patients were ultimately diagnosed with copper deficiency myelopathy secondary to zinc excess, and different treatment regimens are discussed.