Neurohospitalist最新文献

Introduction: Post-Traumatic Stress Disorder (PTSD) is associated with exposure to traumatic events, especially in the military setting. However, patients who experience stroke may develop anxiety about their stroke event and may re-experience transient neurological symptoms as a result. A significant portion develop the persistent and disabling symptoms of PTSD.

Methods: At the University of South Florida, we conducted a single-center, IRB-approved, observational pilot study of 20 adult patients who were diagnosed with stroke or transient ischemic attack (TIA) in the previous 31 days to 1 year. Patients completed the post-traumatic stress disorder checklist-5 (PCL-5), Patient Health Questionnaire-9 (PHQ-9), Stroke specific Quality of Life Scale (SS-QOL-12), Modified Rankin Scale of disability (mRS), and National Institutes of Health Stroke Scale (NIHSS) and provided blood and saliva samples.

Results: All 20 subjects completed the PCL-5 and 19 subjects completed the follow up scales. Seven patients (35%) were found to have Post-Stroke Post-Traumatic Stress Disorder (PS-PTSD). Higher PCL-5 scores were significantly correlated with lower SS-QOL scores indicating worse quality of life (r = -0.709, P = .001) and higher PHQ-9 scores representing symptoms of depression (r = 0.727, P < 0.001).

Conclusion: Post-Stroke Post-Traumatic Stress Disorder (PS-PTSD) is prevalent after stroke and TIA with patients experiencing concurrent depressive symptoms, correlating with a worsened quality of life.

Background and Objectives: We report a rare case of severe posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) in an adult patient with hemophagocytic lymphohistiocytosis (HLH), and speculate that these three diagnoses are related by similar mechanisms of vascular endothelial dysfunction. Methods: Informed consent for this case report was obtained from the patient's legally authorized surrogate decision maker. Discussion and Practical Implications: Our patient initially presented with HLH secondary to intra-abdominal sepsis, and was later found to have severe PRES and RCVS resulting in extensive border-zone cortex infarction. Improvement of the severe systemic inflammatory syndrome characteristic of HLH and arrest of PRES and RCVS progression occurred only after HLH-specific treatment was initiated. In addition to illustrating the potential of HLH to manifest as PRES and RCVS, this case emphasizes the importance of prompt recognition and treatment of HLH and the role the neurologist can play in this process. This case also sheds light on the pathophysiological links between PRES, RCVS, and HLH. These three diagnoses may be related by similar mechanisms of vascular endothelial dysfunction caused by uncontrolled and severe systemic inflammation.

Background and purpose: Recently, institutions have been transitioning to tenecteplase (TNK) as the primary agent for stroke management instead of alteplase (tPA) due to its comparable safety and cost-effectiveness. Despite TNK's potential cost benefits, there's limited literature on how wasted doses impact the overall cost. This study aimed to compare the safety and cost of TNK to tPA following the transition to TNK as the primary agent for acute ischemic stroke (AIS) management at a community hospital.

Methods: This retrospective study compared patients treated with tPA or TNK for AIS. The primary outcome was a composite of intracranial hemorrhage, any other bleed, and death from any cause. Secondary outcomes included the individual components of the primary outcome, length of hospitalization, time from administration decision to medication administration, readmission rate, medication costs, and wasted doses.

Results: 48 AIS patients who received either tPA or TNK between November 2021 and February 2024 were included. TNK didn't result in more occurrences of the primary outcome compared to tPA (OR 1.00, 95% CI 0.25 to 4.03). The TNK group had a shorter median length of hospitalization and decreased elapsed time from administration decision to administration. The cost difference between a 50 mg kit of TNK and a 100 mg vial of tPA is about $1100. The total number of wasted doses was 10 for tPA and 12 for TNK.

Conclusions: There was no difference in safety between TNK and tPA. While TNK offers cost savings, poor waste management could undermine its overall cost-effectiveness.

Background and objectives: Teleneurology has become instrumental in extending neurologic care in remote and underserved areas, enhancing access, and potentially improving patient outcomes while reducing costs. This study evaluates the satisfaction of both patients and healthcare providers with teleneurology services for common neurological disorders.

Methods: In this single-center, prospective observational study, 58 patients suffering from headache, epilepsy, stroke, or dementia were recruited through the "Karnataka Brain Health Initiative." Teleconsultations were facilitated via Zoom, incorporating brief neurological examinations. Satisfaction levels were gauged using the Telemedicine Satisfaction Questionnaire (TSQ) for patients and the Patient and Physician Satisfaction with Monitoring Questionnaire (PPSM) for healthcare providers.

Results: Of the 58 patients enrolled, 18 had headache, 12 epilepsy, 13 stroke, and 15 dementia, with a mean age of 43.7 years. All completed the TSQ, yielding a mean score of 4.47 ± 0.41. The average teleconsultation lasted 21.21 minutes. The PPSM questionnaire, completed by neurologists for all patients, resulted in a mean score of 4.33 ± 0.44. Of these, 36 consultations initiated by primary care physicians had a PPSM mean score of 4.47 ± 0.51. Agreement on quality of care was 60%, time-saving benefit 98%, and willingness for future use 95%.

Discussion: The findings indicate high satisfaction among both patients and providers, underscoring the effectiveness of teleneurology in delivering quality care comparable to in-person consultations. The positive feedback from primary care physicians highlights teleneurology's potential as an integral component of healthcare delivery in low-resource settings.

Background: syphilis is globally recognized as a great imitator due to its multiple manifestations and multi-organ involvement. This holds especially true in the context of neurosyphilis (NS), where stroke and other cerebrovascular manifestations are frequently overlooked. With the global reemergence of syphilis, meningovascular syphilis (MVS) and other vascular syphilitic affectations are now important, yet underdiagnosed causes of ischemic stroke. Purpose: this literature review focuses on syphilis in the context of stroke, examining the condition through this specific perspective. The pathophysiological aspect focuses on immune-mediated endothelial injury and vascular inflammation as main mechanisms leading to stroke. Analysis: a broader approach to syphilis is initially described, showcasing the comprehensive medical workup necessary for accurate diagnosis of MVS and special treatment considerations. Diagnostic challenges of NS are initially exposed, with cerebrospinal fluid (CSF) analysis and neuroimaging playing critical roles. While CSF-VDRL remains the gold standard, although, its low sensitivity necessitates a multimodal diagnostic approach combining serological, clinical, and radiographic findings. MRI and angiographic studies often reveal concentric steno-occlusive arteriopathy, most commonly affecting the middle cerebral and basilar arteries. Early recognition is vital, as NS can mimic common neurovascular etiologies, particularly in the context of younger adults without traditional risk factors. Treatment involves intravenous penicillin G, corticosteroids and antiplatelet agents playing supportive roles. However, clinicians must weigh bleeding risks in specific cases, particularly in patients with syphilitic aneurysmal disease. Conclusions: timely diagnosis and treatment of NS and MVS are essential to prevent irreversible neurological damage and contribute to the reduction of global stroke burden.

Introduction: Low levels of Vitamin D are associated with severe manifestations of autoimmune or inflammatory diseases; there is limited information regarding Guillain-Barré Syndrome (GBS).

Objective: To determine the serum levels of vitamin D in patients with GBS compared with healthy controls.

Materials and methods: A prospective observational study of consecutive patients with GBS based on EAN/PNS criteria over a year, from a single center was conducted. Clinical and paraclinical characteristics were obtained from the included patients upon admission; we determined the serum levels of Vitamin D (ng/ml) at admission and categorized them according to Vitamin D levels: sufficient >30 ng/mL, insufficient 20-30 ng/mL, and deficient <20 ng/mL. Poor prognosis was considered as non-independent walking at 3 months follow-up.

Results: The study included 56 patients with GBS (Guillain-Barré Syndrome) and 56 healthy control patients. The control group exhibited higher median levels of vitamin D compared to the GBS patient group [(29.9 ng/dl (IQR 24-34.8) vs 17.1 ng/dl (IQR 13.7-23.8 ng/dl), P < 0.001]. Only 9% (95% CI 1-19%) of the GBS patients had sufficient levels of vitamin D. In correlation analysis, significant differences were found between Vitamin D levels and glucose levels (r2 = -.36, P = 0.007) and the glucose-leukocyte index (GLI) (r2 = -.42, P=<0.001). In comparative analysis (Vitamin D levels ≤15 ngs/ml/ vs ≥ 16 ng/mL), the presence of dysautonomias, facial diparesis, leukocytes, glucose-leukocyte index (GLI), and glucose levels were significant; in the Kaplan-Meier survival analysis, patients with Vitamin D levels ≤15 ngs/ml showed lesser recovery in independent walking at 3 months (log-rank = 0.047).

Conclusion: Patients with GBS and low levels of Vitamin D exhibit a higher frequency of dysautonomias, higher GLI, and lesser recovery of independent walking.

Late-onset Pompe disease is a rare autosomal recessive lysosomal storage disorder caused by acid α-glucosidase deficiency, resulting in progressive skeletal muscle weakness and respiratory failure. We present the case of a 43-year-old African American woman who was admitted to the intensive care unit with acute-on-chronic hypoxemic and hypercarbic respiratory failure, alteration of consciousness, and progressive weakness. Her recent medical history included respiratory distress and aspiration pneumonia, which had not fully resolved despite supplemental oxygen therapy. On admission, initial evaluations including imaging and laboratory tests did not reveal a diagnosis. Muscle biopsy showed a vacuolar myopathy with excess glycogen suggestive of glycogen storage disease. Enzyme testing was obtained through the dried blood spot testing and was low. Molecular genetic testing identified two pathogenic variants in the GAA gene, confirming the diagnosis of late-onset Pompe disease. This diagnosis enabled the prompt initiation of enzyme replacement therapy (ERT) with alglucosidase alpha. The early initiation of ERT in this patient was pivotal in managing her condition, given the progressive nature of late-onset Pompe disease and the potential for improved outcome when treatment is started early. This case highlights the importance of considering late-onset Pompe disease in adults presenting with unexplained progressive respiratory and neuromuscular symptoms. It also demonstrates the critical role of biochemical and molecular genetic testing, as early intervention can significantly impact treatment outcomes and quality of life.

Background: Thyrotoxic periodic paralysis (TPP) is a rare, life-threatening, reversible condition, in which episodic muscle weakness occurs due to low serum potassium in the setting of thyrotoxicosis. In addition to treating thyrotoxicosis, prompt restoration of potassium levels is essential while monitoring for rebound hyperkalemia. Purpose: To emphasize the importance of recognizing and appropriately managing TPP, with a focus on the potential dangers of potassium overcorrection. Case Report: We present a patient with TPP whose potassium replacement therapy caused dangerous hyperkalemia, requiring aggressive potassium shifting and wasting therapies and vasopressor support. Conclusions: This case report highlights the importance of prompt recognition and treatment of TPP as well as the need for careful management of potassium levels to prevent respiratory failure and cardiac arrhythmias. We discuss the challenges associated with potassium repletion in thyrotoxicosis including the importance of careful monitoring and titration of potassium replacement therapy to avoid overcorrection and hyperkalemia.

This article highlights herpes zoster radiculitis, a condition that predominantly affects elderly patients and classically presents with progressive limb weakness, pain, and vesicular rash. Neuroimaging with MRI may demonstrate nerve root enlargement with T2-hyperintensity and gadolinium enhancement. Diagnosis can be confirmed with varicella zoster virus PCR in CSF. Effective treatment includes IV acyclovir and neuropathic pain agents such as gabapentin, which together can lead to symptomatic improvement. Early diagnosis and comprehensive treatment are crucial to prevent complications. Patients with zoster-associated plexopathy have a higher incidence of postherpetic neuralgia compared to those with herpes zoster rash alone. Thus, multimodal treatment involving antivirals, rehabilitation, and pain management is essential for recovery.