Neurohospitalist最新文献

A 66-year-old female patient presented with progressive short-term memory loss over a period of three months and mild gait imbalance. MRI of the brain demonstrated symmetric expansile T2 FLAIR hyperintensities within the bilateral mesial temporal lobes, thalami, and cingulate gyri (Figure 1). Due to the symmetry of the signal changes in the bilateral cerebral hemispheres and especially the mesial temporal lobes, an autoimmune encephalitis was strongly favored on imaging. Glioblastoma was a consideration on the initial scan; however, it was thought to be much less likely, and the patient received immunosuppression with plasmapheresis and IV steroids. At that time, it was even presumed that the patient improved mildly with plasmapheresis. The patient was discharged on PO steroids; however, a few weeks later the patient presented in status epilepticus. On repeat MRI brain, findings were not significantly changed, and the diagnosis of an autoimmune process was again favored on imaging. The patient received plasmapheresis and IV steroids. However, on the second admission the patient's neurologic function was markedly below baseline per the family's report. The patient had received an extensive autoimmune, infectious and metabolic work up, including testing for Creutzfeldt-Jacob disease, with all the tests coming back negative. Therefore, a brain biopsy was performed to understand the underlying pathology, IDH wild-type glioblastoma. On MRI, the expansile signal changes were bilateral and multifocal, affecting more than three cerebral lobes. This is a case of gliomatosis cerebri, which was misdiagnosed as autoimmune encephalitis due to the symmetry of cerebral involvement.

A 13-year-old boy developed right-sided Horner's syndrome following resection of a benign mediastinal schwannoma extending from T1 to T3. Postoperatively, he exhibited ptosis, miosis, and anhidrosis, confirmed by starch iodine testing. The tumor likely involved the upper thoracic sympathetic ganglia-a rare site for schwannomas. This image highlights a rare iatrogenic cause of preganglionic Horner's syndrome. While Horner's is classically associated with apical lung or cervical lesions, this case emphasizes the importance of recognizing postoperative Horner's syndrome as a clinical clue to cervicothoracic sympathetic injury. It highlights the value of anatomical-clinical correlation in localizing lesions along the sympathetic pathway.

Movement disorders may be a core feature of autoimmune brain disorders, including paraneoplastic neurological syndromes. A 73-year-old white male presents with memory impairment, gait instability, dysphagia, and severe dysarthria progressing over 1.5 years. He recently developed behavior and sleep disturbances. His cognitive assessment showed time disorientation, short-term memory impairment with preserved retrieval, and pseudobulbar affect. The remainder of the neurological exam showed seborrhea, facio-cervical dystonia, a right positive palmomental reflex, fragmented pursuit eye movements, dysarthria, minor right pyramidal signs, bilateral asymmetric limb ataxia and symmetric akinetic parkinsonism. He was wheelchair-bound, capable of only a few short steps with help. MRI depicted generalized cortico-subcortical atrophy with temporal predominance. He was positive for antibodies anti-Hu in serum (1:10 000) and CSF (1:100), as antibodies anti-NMDAR in serum (1:320) and CSF (1:10). The patient had no clinical improvement after a therapeutical trial with 1 g intravenous methylprednisolone. Additional workup for occult neoplasia was positive for prostatic adenocarcinoma. He remains stable 2.5 years after disease onset.

Introduction: Early neurological deterioration (END) in ischemic stroke (IS) patients is a common complication that significantly impacts functional and vital prognoses. We aimed to determine the prevalence, predictors, and 90-day outcomes of END in Tunisian stroke patients.

Materials and methods: This was a retrospective cohort study of consecutive stroke cases admitted at the Neurology Department of the University Hospital in Monastir over 5 years, from 2018 to 2022. We included patients with an increment of two or more points on the NIHSS score within the first 7 days following IS. Univariate analysis and binary logistic regression were performed to identify independent factors associated with END.

Results: We included 489 patients with a mean age of 64 years (24 to 90) and a male predominance (sex ratio M/F = 1.86). The prevalence of END was 12.06% (59/489 patients). An elevated initial NIHSS score (OR = 1.13; 95% CI = 1.05-1.21), anterior choroidal artery stroke (OR = 5.39; 95% CI = 1.99-14.55), and large artery atherosclerosis (OR = 2.85; 95% CI = 1.17-6.9), were found to be independent factors associated with END. The causes of END included IS recurrence (12%), hemorrhagic transformation (10%), brain edema (10%), and stroke progression (68%). At 90 days, 80.8% (P < 0.001) of patients who experienced END had a mRS score of 2 or more, with a mortality rate of 18.6% (P < 0.001).

Conclusion: Patients with elevated NIHSS scores, AChA strokes, or LAA, should be prioritized for close observation during the acute phase. Enhancing our understanding of the predictive factors of END following IS could help target patients at very high risk of END and facilitate the development of more effective and rigorous strategies for prevention and treatment.

Objectives: To discuss utility of using DWI-FLAIR mismatch in select patients not included in the original WAKE-UP trial for administration of IV thrombolytics.

Methods: We identified a female over 100 years old who presented with stroke symptoms upon waking up. This case is selected due to its unique management. Relevant clinical data was collected through a review of the patient's medical records. All data were anonymized to ensure confidentiality.

Results: A 102-year-old female with a complex past medical history of atrial fibrillation, not on anticoagulation presented with a National Institutes of Health Stroke Scale (NIHSS) of 23. Stroke symptoms were present upon awakening. Noncontrast computed tomography (CT) of the head was negative for hemorrhage or early ischemic changes. CT angiography (CTA) of the head and neck was notable for a distal right M2 occlusion. A hyperacute magnetic resonance imaging (MRI) of the brain was pursued to determine potential eligibility for intravenous thrombolysis (IVT). Patient consented to IVT. NIHSS improved to 13. She was eventually discharged to a skilled nursing facility.

Discussion: We aimed to highlight the oldest known case of IV thrombolysis in this patient presenting with a stroke upon awakening. This is to emphasize possible benefit in cases not included in the original WAKE-UP trial.

A 51-year-old woman presented with acute onset of a severe headache, and was found to have diffuse subarachnoid hemorrhage with prominent cisternal and left cortical convexity blood on head computed tomography. The first 2 conventional angiograms were negative for aneurysm, but a third angiogram revealed a mycotic aneurysm of a distal left middle cerebral artery branch. Brain biopsy, associated with clipping of the aneurysm, demonstrated pathology consistent with vasculitis. Over the course of a month, she developed diffuse, serpiginous dolichoectasia of the cerebral arteries. Further investigation into the cause of vasculitis supported a diagnosis of either eosinophilic granulomatosis with polyangiitis (EGPA) or IgG4-Related Disease (IgG4-RD). The following clinical pathologic conference discusses the diagnostic challenges in discriminating between these 2 diseases, particularly in the setting of secondary angiitis of the central nervous system.

Background: Monitoring stroke patients in critical-care units for 24 h after thrombolysis or endovascular thrombectomy is considered standard of care in current guidelines but is not evidence-based. Due to the COVID-19 pandemic, our center adopted a targeted protocol in April 2021 with 24-h critical-care monitoring no longer being guaranteed for stroke patients receiving reperfusion treatment. We aim to compare the incidence and timing of complications during the year under the targeted approach compared to prior years when the standard of care was followed.

Methods: We conducted a single-center retrospective cohort study. We analyzed data from stroke patients treated with thrombolysis and/or endovascular thrombectomy in 2019 (pre-COVID-19, standard of care), 2020 (during COVID-19, standard of care) and 2021 (during COVID-19, targeted protocol). Data extracted included demographics, the nature and timing of complications within the first 24 h, and the unit at the time of complication.

Results: Three hundred forty-nine patients were included in our study: 78 patients in 2019, 115 patients in 2020, and 156 patients in 2021. In 2021, 32% of patients experienced at least 1 complication within the first 24 h compared to 34% in 2020 and 27% in 2019. In 2021, 33% of patients admitted to critical-care units had a complication compared to 29% in non-critical care units. In 2021, 70% of complications had occurred by hour 8 compared to 49% in 2020 and 29% in 2019.

Conclusions: The incidence and timing of complications did not significantly worsen under the targeted approach compared to prior years and were not associated with hospital location.

Spontaneous vertical eye movements in the critical care setting are often a source of confusion and alarm; while their origin remains at least partly theoretical, understanding their classification and associated clinical implications can inform the diagnostic workup and further clinical management. This case describes a patient who demonstrated ocular dipping: slow conjugate downward eye movements with a quick return to primary gaze. Ocular dipping is a rare phenomenon that was initially described in patients with hypoxic brain injury and has since been described in only a handful of cases. Dipping resides in a spectrum of spontaneous vertical eye movements, with ocular bobbing being the first of these described eye movements. Ocular bobbing is characterized by a fast downward movement followed by a slow return to the mid gaze position which is classically associated with pontine injury. Other vertical eye movements that can be seen in patients with a disorder of consciousness include other variations of ocular bobbing and dipping, vertical myoclonus, and small-amplitude mainly vertical movements.