Neurohospitalist最新文献

Meningitis and encephalitis are neurologic emergencies that require immediate management and current guidelines recommend empiric treatment with broad-spectrum antimicrobials. Cerebrospinal fluid (CSF) testing algorithms are heterogeneous and largely institution-specific, reflecting a lack of consensus on how to effectively identify CSF pathogens while conserving resources and avoiding false positives. Moreover, many lumbar punctures (LPs) performed in the inpatient setting are done for noninfectious workups, such as evaluation for leptomeningeal metastasis. As such, tailoring CSF testing to clinical context has been a focus of multiple prior reports and several healthcare systems have focused on efforts to limit low-yield diagnostic testing when a positive result is unlikely. To curb ordering viral PCRs when pre-test probability is low, some peer institutions have implemented pleocytosis criteria for virus-specific polymerase chain reaction (PCR) tests from CSF. In this report, we retrospectively analyzed the diagnostic testing of CSF from patients who had an LP while admitted to a single, large academic medical center and found that many cases of Herpes Simplex Virus (HSV) meningoencephalitis were diagnosed by non-neurologists. The rate of positive virus-specific PCR tests was very low, and tests were frequently ordered in duplicate with a multiplexed meningitis/encephalitis PCR panel (M/E panel, BioFire, Salt Lake City, UT). We designed and implemented a systems-level intervention to promote a revised stepwise testing algorithm that minimizes unnecessary tests. This intervention led to a significant reduction in the number of low-yield virus-specific PCR tests ordered without implementing a policy of cancelling virus-specific PCRs.

Background: We sought to determine mobilization practices following emergency stroke therapy in centers across the United States.

Methods: We surveyed hospitals in the NIH StrokeNet regarding mobilization practices following acute stroke thrombolysis and/or thrombectomy. An anonymous survey was sent out to all StrokeNet sites Survey questions included stroke center designation, location of admission, whether a formal bed rest protocol was in place, minimum bed rest period required, which person first mobilized the patient.

Results: 48 centers responded to the survey including 45 Comprehensive Stroke Centers and 3 Primary Stroke Centers. Most patients were admitted to a neuro-intensive care unit (54%), others to a general medical/surgical ICU, stroke ward, or combination. 60% of respondents indicated that a formal bed rest policy was in place. Minimum bed rest requirements after thrombolysis alone ranged from 0 to 24 hours (35% with a 24-hour bed rest protocol, 19% with no minimum, 13% with a 12-hour minimum, 4% with an 8-hour minimum, 4% with a 6-hour minimum, and 6% with a variable rest period). Similar variations were reported in patients undergoing thrombectomy with ranges from 0 to 24 hours bed rest. First mobilization was by a nurse 52% of the time and by a physical therapist 48% of the time.

Conclusions: Mobilization practices following emergency ischemic stroke reperfusion treatments vary significantly across stroke centers. Mobilization of patients is performed primarily by nurses and therapists. Further study regarding an optimal approach for mobilization following acute ischemic stroke thrombolysis and/or thrombectomy is warranted.

Background: Vision loss accounts for most ophthalmic presentations of giant cell arteritis (GCA), but an important minority of patients present with diplopia and other cranial neuropathies. Case study: Here we present the case of an 84-year-old woman with a prior history of multiple cancers who was admitted to our hospital after developing double vision. She was found to have mydriasis, ptosis, and ophthalmoplegia in the right eye (OD) consistent with a combined R CNIII/CNVI neuropathy, as well as highly elevated inflammatory markers. Given her cancer history, the patient was initially worked up for various neoplastic, paraneoplastic, inflammatory, and infectious causes of multiple cranial neuropathies; however, as these results were negative, GCA became a more likely contender as a possible rare cause of multiple cranial neuropathies. The patient underwent temporal artery biopsy which showed pathology consistent with giant cell arteritis, and she was treated with steroids with eventual improvement in ophthalmoplegia and ptosis. Conclusions: This case illustrates the importance of recognizing GCA as a rare possible cause of multiple cranial neuropathies, including the indispensable role of temporal artery biopsy.

Promethazine, a common antiemetic, can cause severe tissue injury with intravenous (IV) injection. Dihydroergotamine (DHE), commonly used for the acute treatment of migraine, can cause arterial vasoconstriction. We report a rare complication of brachial artery vasospasm in a patient receiving IV promethazine and DHE sequentially through the same midline IV catheter. A 40-year-old woman with history of migraine headaches and Raynaud phenomenon was admitted for treatment of status migrainosus with scheduled IV DHE infusions. While receiving the DHE infusions, IV promethazine was added to the patient's regimen to treat nausea. During an infusion of DHE, the patient developed acute pain near the catheter insertion site due to active extravasation of IV DHE. An arterial Doppler ultrasound demonstrated stenosis in the right brachial artery near the region of infusion. The patient ultimately required balloon angioplasty and intra-arterial injection of nitroglycerin to restore adequate blood flow. We hypothesize that caustic injury to the right brachial vein from IV promethazine predisposed the patient to the extravasation of DHE, which, in turn, caused adjacent brachial artery vasospasm. This case suggests the need for careful consideration, if not strict avoidance, of the use of concurrent IV promethazine and DHE.

Transverse myelitis (TM) is an inflammatory syndrome of the spinal cord that presents with acute-to-subacute neurological deficits. The differential for TM is broad and includes demyelinating, infectious, neoplastic and paraneoplastic, autoimmune, and metabolic/toxic etiologies. With the novel severe acute respiratory syndrome coronavirus pandemic, more commonly referred to as the coronavirus infectious disease of 2019 (COVID-19), there have been increasing reports of neurological complications. In this case report, we describe a novel case of longitudinally-extensive TM associated with the Moderna vaccination.

Contactin-associated protein-like 2 autoimmunity is an uncommon disorder resulting in peripheral nerve hyperexcitability or encephalitis. In a fifth of cases, onset may be provoked by thymoma, but other associations are largely unknown. We report a patient with anti-contactin-associated protein-like 2-related peripheral nerve hyperexcitability arising in the setting of Charcot-Marie-Tooth type 4F and discuss potential mechanisms underlying the association.

Background: This is a case of multifocal intracranial stenosis in a 74 year old male ultimately discovered to be due to Varicella Zoster Virus infection. Purpose: We highlight the importance of a broad differential diagnosis, even when the most likely etiology of intracranial stenosis is atherosclerosis. Our paper reviews the differential diagnosis as well as "red flags" for intracranial vasculopathy. Even though intracranial atherosclerotic disease is the most common cause of vasculopathy, infectious or inflammatory vasculitis should be considered on the differential. Conclusions: Before considering bypass surgery or other invasive neurosurgical procedures, ensure reversible causes of vasculopathy have been ruled out. The presence of cranial neuropathies, rash, and/or elevated inflammatory markers should be red flags for vasculitis in patients presenting with stroke.