Neurohospitalist最新文献

Brain metastases in prostate cancer are rare (<2% of cases). In magnetic resonance imaging, nearly all brain metastases exhibit contrast-enhancement, which may be affected by the time elapsed since the administration of the contrast agent. We discuss a case where the brain metastases in a patient with prostate cancer do not show a clear contrast-enhancement on magnetic resonance imaging using a standard brain metastases protocol. It also emphasizes the usefulness of delayed imaging in identifying blood-brain barrier damage. We present the case of a 69-year-old man diagnosed with prostate adenocarcinoma, currently in castration-resistant phase (last value of serum prostate-specific antigen: 45.1 ng/mL) with bone, mediastinal and inguinal lymph nodes, pulmonary, and hepatic metastases. In a contrast-enhanced whole-body computed tomography examination, the appearance of intra-axial brain lesions suspicious for metastases was documented. The subsequent contrast-enhanced brain magnetic resonance imaging showed the presence of 5 intra-axial lesions consistent with brain metastases. These lesions exhibited hyperintense signals in T2-fluid-attenuated inversion recovery images; after contrast agent administration, a ring-like contrast-enhancement was more clearly visible in T1-weighted images acquired later (about 15 minutes after contrast agent administration) than in those acquired earlier (about 5-7 minutes after contrast agent administration). In conclusion, for oncological subjects with multiple brain lesions lacking obvious contrast-enhancement using a standard magnetic resonance imaging protocol, we suggest acquiring late images. These might allow for the detection of even minimal post-contrast impregnation, improving confidence in the diagnosis of brain metastases.

We report a case highlighting key clinical, CSF, and imaging findings of primary diffuse leptomeningeal gliomatosis of the spine.

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.

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.

Deterioration of a patient's state of consciousness is among the most concerning signs encountered in clinical practice. The evaluation of this finding carries a broad initial differential diagnosis and must account for any relevant medical history. We describe the case of a 41-year-old male with known retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations (RVCL-S) who presented with progressive mental status decline and acute onset intractable headache. Head computed tomography (CT) revealed extensive vasogenic edema, resulting in right to left shift of 11 millimeters at the level of the lateral ventricles, with associated uncal and subfalcine herniation. He was treated with a 5-day course of methylprednisolone, leading to resolution of his lethargy and headache. Follow up neuroimaging with magnetic resonance (MRI) brain demonstrated interval improvement with the midline shift reduced to 3 millimeters after completion of high dose corticosteroids. Neurosurgical intervention was considered, but ultimately not required given his improvement. This case describes the management of life-threatening cerebral edema as a complication of RVCL-S disease progression. Due to the rarity of this disease, there are no standardized guidelines for treatment and the care for such patients relies on expert opinion, case studies, and extrapolation of principles learned from related conditions. Our intention is that the reporting of this case will contribute to the limited body of literature and aid those affected by this condition.

Background: Moyamoya disease (MMD) is a rare pathological state characterized by progressive stenosis of the terminal portion of the internal carotid arteries (ICA). Complications include both ischemic and hemorrhagic strokes, for which there is no curative treatment for MMD. Early diagnosis with surgical intervention is vital for there is no definitive treatment. Due to the bimodal age distribution, moyamoya should be considered for patients presenting with stroke and supraclinoid ICA vasculopathy.

Case: We present a case of a 23-year-old female who presented with left arm weakness and sudden onset thunderclap headache. Upon further questioning, it was revealed that the patient had started an estrogen-containing birth control two weeks prior to presentation. Neuroimaging at our tertiary care center demonstrated simultaneous ischemic and hemorrhagic strokes in the bilateral hemispheres associated with vasculopathy seen in both invasive and noninvasive cerebrovascular imaging. She was diagnosed with idiopathic moyamoya disease since her serum and cerebrospinal fluid studies did not reveal any obvious precipitators to suggest moyamoya syndrome (MMS).

Conclusion: There were no obvious precipitating factors identified in the extensive workup for this patient. Therefore, further secondary prevention is difficult for this otherwise young and healthy individual. While there is data to support the use of antiplatelet medications for the prevention of ischemic stroke secondary to intracranial atherosclerotic disease, there are no clear guidelines for the treatment of MMD that simultaneously causes ischemic and hemorrhagic stroke. Further research on the pathophysiology and treatment modalities for MMD are needed to guide clinicians in treating this complex disease.

Background: Impingement of an elongated styloid process (ESP) or calcified stylohyoid ligament on surrounding neck structures defines Eagle syndrome. The vascular variant, also called stylocarotid syndrome, results from impingement of vascular structures and remains poorly known among physicians. Research Design: We report our own experience and review the literature in order to clarify the diagnostic and therapeutic management. Patients with vascular events in relation to an ESP and hospitalized at our institution were extracted from our databank and retrospectively reviewed. We also performed a comprehensive review of the literature on Eagle syndrome using PubMed® and Google Scholar, analysing the presentation, management, and follow-up. Results: We report five cases of the vascular variant of Eagle syndrome: one carotid perforation, one focal arteriopathy, one with both acute and chronic dissection and two acute internal carotid dissection. Vascular compression, whether permanent or transient, is also reported in the literature. Management varies, although styloidectomy is deemed appropriate for symptomatic compression, while stenting is preferred in cases of perforation. Conclusions: A common definition of Eagle syndrome is required for better diagnosis and management. The choice of styloidectomy is understandable for compression but remains to be investigated in other cases.

Background and purpose: Aneurysmal subarachnoid hemorrhage (aSAH) carries high morbidity and mortality with survivors often requiring extended care at skilled nursing facilities (SNF). Predictors of SNF discharge to home (SNFdcH) remain unclear.

Methods: Retrospective review of a single-center prospectively maintained aSAH database from June 2016-March 2024 was conducted. Patients discharged to SNF were grouped by subsequent discharge to home. Predictors of discharge to home and facility length of stay (LOS) were determined using t-tests, Fisher analyses, and cumulative link modeling.

Results: Of 450 aSAH patients, 61 (13.5%) were discharged to SNFs. 49 (80.3%) returned home, with 61% achieving mRS <3 at discharge. Discharged patients were younger (mean 63.3 ± 11.5 vs 70.2 ± 9.3 years, P = .040) with lower median modified Fisher scores (3 [IQR 3-4] vs 4 [4-4], P = .046). Tracheostomy (OR = .14, 95% CI [.02, .75], P = .023) and gastrostomy tube (PEG) placement (OR = .13, 95% CI: .03-.51, P = .003) decreased the odds of SNFdcH. Discharged patients had shorter hospital LOS (26 ± 10 vs 39 ± 15 days, P < .001) and lower median modified Rankin scores (mRS) at hospital discharge (4 [4-5] vs 5 [4-5], P = .028) and at 90 days post-discharge (4 [3-5] vs 6 [5-6], P = .001). Multivariable regression identified age, PEG, and hospital LOS as predictors of SNFdcH. Tracheostomy and PEG predicted SNF LOS.

Conclusions: Most aSAH patients discharged from SNFs returned home, with 61% achieving mRS <3. Patients not discharged were medically complex with neurological deficits. These findings may guide care discussions and highlight the role of SNFs in bridging hospitalization and independence.

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.