Neurologist最新文献

Objectives: Tenecteplase is an emerging alternative to Alteplase in the management of acute ischemic stroke (AIS). Strong evidence supports the noninferiority of Tenecteplase compared with Alteplase in AIS. Tenecteplase is often preferred due to its affordability, ease of administration, and superior recanalization potential in large vessel occlusion. In this study, we report on the safety and effectiveness of routine Tenecteplase use in a large telestroke network in eastern India.

Methods: This retrospective observational study analyzes patient records collected under the Swasthya Ingit Telestroke Program in West Bengal, India. AIS patients who underwent thrombolysis in the 41 hospitals of the Swasthya Ingit Telestroke Network between January 2022 and December 2024 were included in this study. Patients receiving Tenecteplase were compared with those receiving Alteplase. The percentage of patients achieving a good outcome (defined as a score of 0 to 2 on the modified Rankin scale at 90 d), the rate of symptomatic intracranial hemorrhage, and all-cause mortality within 3 months were the main parameters of comparison between the 2 thrombolytic agents.

Results: A total of 1526 patients were included in this study. Of these, 1389 patients received Tenecteplase, while 137 patients received Alteplase. Mixed-effects multivariable logistic regression did not demonstrate any association between the thrombolytic agent used and favorable outcomes [Tenecteplase odds ratio: 1.03 (95% CI: 0.56-1.87), P=0.93], symptomatic intracranial hemorrhage [Tenecteplase odds ratio: 0.63 (95% CI: 0.21-1.87), P=0.41], or all-cause mortality [Tenecteplase odds ratio: 0.54 (95% CI: 0.24-1.24), P=0.15].

Conclusion: The routine use of Tenecteplase for managing acute ischemic stroke appears to be safe and effective in real-world practice.

Introduction: Foster Kennedy syndrome classically occurs in frontal space-occupying lesions (SOL). It describes the appearance of optic atrophy in one eye and optic nerve swelling in the other. Optic atrophy occurs due to direct compression from lesion (on the ipsilateral side) and optic nerve head swelling occurs due to increased intracranial tension due to mass effect (on the contralateral side).

Case report: We report a case of a 37-year-old female presenting with a right SOL, yet left optic nerve atrophy and right optic nerve head swelling; inverse Foster Kennedy syndrome.

Conclusion: Inverse Foster Kennedy syndrome is a rare entity that should be taken into consideration when reviewing a patient with optic atrophy in one eye and swelling in the other.

Introduction: Glutamic acid decarboxylase 65 (GAD65) antibody-associated temporal lobe epilepsy (GAD65-TLE) is a rare form of autoimmune-associated epilepsy characterized by medically refractory seizures and cognitive decline. Diagnosis typically requires antibody testing and clinical correlation, and treatment options include immunotherapy and antiseizure medications (ASMs). However, many patients experience persistent or worsening symptoms despite ongoing treatment.

Case report: A 20-year-old woman presented with mild cognitive impairment and focal aware seizures that gradually progressed in frequency and severity. A diagnostic workup revealed GAD65-TLE, and the patient began treatment with intravenous methylprednisolone infusions and antiseizure medications within 6 months of her presentation. After 20 months of treatment, the patient was on stable doses of levetiracetam and lamotrigine and finished tapering immunosuppressive therapy with methylprednisolone. The frequency of her focal aware seizures significantly decreased, whereas the focal impaired aware and focal bilateral tonic-clonic seizures resolved. The patient was able to return to all of her previous daily activities.

Conclusions: In patients presenting with new-onset seizures characterized by unusual semiology and frequent focal aware seizures, it is crucial to consider GAD65-TLE in the list of potential diagnoses. Delayed diagnosis may lead to resistance to both ASMs and immunotherapy. This case report emphasizes how prompt identification and early initiation of immunotherapy can significantly impact the course of the disease.

Objectives: A cluster analysis was conducted to classify the 7 different cognitive domains affected by PSCI patients, to explore the correlation and similarity between cognitive domains and provide a basis for targeted intervention.

Methods: We collected demographic and disease-related data from 724 PSCI patients. We used Python 3.8 software to perform K-means clustering and hierarchical clustering on the 7 cognitive domains assessed by the MoCA scale, and used the silhouette coefficient to determine the optimal number of clusters k.

Results: The results of K-means clustering and hierarchical clustering show that the 7 dimensions of MoCA can be grouped into 2 categories. Cluster 1 scored lower in the cognitive areas of visual space and executive function, attention, language, abstraction, and delayed recall, whereas cluster 2 had higher scores in the naming and orientation domains. The scores in all cognitive domains of cluster 1 are lower than those of cluster 2, indicating severe cognitive impairment. Compared with cluster 2, the subjects in cluster 1 have poor physical health, living conditions, economic status, and social support ability.

Conclusions: The 7 dimensions of MoCA can be divided into 2 categories. In clinical practice, health care professionals should pay special attention to the severity of the patient's condition, the affected area, and individual differences, and develop precise and personalized treatment plans to improve the patient's cognitive function and quality of life.

Objectives: Cervical artery dissection (CeAD) is an important cause of ischemic stroke in young adults. Nearly 100 million annual chiropractic cervical manipulations are performed in the United States. The relationship between manipulation and CeAD remains controversial.

Methods: We analyzed patients in the multicenter STOP-CAD registry (n=4023) to identify CeAD cases diagnosed after chiropractic cervical manipulation. Demographics and clinical features were compared between manipulation-associated and nonmanipulation-associated cases using χ 2 and t tests. Multivariable logistic regression identified key factors associated with manipulation-related CeAD.

Results: About 1 in 20 CeAD cases in this registry reported antecedent cervical manipulation. In multivariable binary logistic regression, compared with patients without prior manipulation, those with prior manipulation were younger (OR per year 0.98, 95% CI: 0.97-0.99, P =0.014), more often female (OR: 1.64, 95% CI: 1.21-2.23, P =0.001), less often diabetic (OR: 0.24, 95% CI: 0.08-0.78, P =0.018), presented with neck pain (OR: 2.80, 95% CI: 2.08-3.77, P <0.001), and had higher odds of isolated vertebral artery dissection (OR: 2.15, 95% CI: 1.57-2.94, P <0.001). Recurrent ischemic stroke rates were similar between groups.

Conclusions: Given the very high number of manipulations performed annually, the absolute risk of secondary CeAD is extremely low. Manipulation-associated cases have distinct clinical features, occurring more often in younger women with vertebral dissections. Whether manipulation acts as a precipitating trigger or patients with early CeAD symptoms seek manipulation remains unresolved.

Introduction: Myasthenic crisis (MC) is the most serious manifestation of myasthenia gravis (MG) and it poses a big challenge in clinical management. Plasma exchange and intravenous immunoglobulin are the first-line therapy for MC, but a subset of patients exhibit poor response. Recently, neonatal Fc receptor (FcRn) inhibitors and complement inhibitors showed great efficacy in MC. However, there is no report on whether eculizumab can serve as a rescue therapy for patients who have not responded to efgartigimod.

Case report: This case report describes a Chinese patient with generalized MG who experienced an acute exacerbation and suffered from MC. Despite poor responsiveness to efgartigimod, the patient was successfully rescued with eculizumab. Under regular treatment with eculizumab once every 2 weeks, the patient achieved a status of minimal symptom expression. However, the efficacy of eculizumab in MC has yet to be confirmed through more clinical trials.

Conclusions: This case report hints the potential of complement inhibitors as viable treatments alternative for MC patients who poorly respond to antibody-clearing therapy. Besides, further research is necessary to determine the preferred or suitable treatment option for specific patients.

Background: Various artificial intelligence-based medical technologies have been used for diagnosing and treating diseases. Although moyamoya disease (MMD) poses a significant threat to the lives of patients, artificial intelligence (AI) use in MMD is still limited.

Review summary: This study aims to review the literature on predicting, diagnosing, and treating MMD with AI, as well as to discuss its current status, challenges, and future directions. Using AI in treating MMD can enhance diagnostic accuracy and treatment outcomes. AI-driven imaging analysis aids in the early detection of vascular abnormalities linked to MMD, facilitating timely intervention and management. In addition, machine learning (ML) algorithms can analyze large data sets from clinical trials and patient records to identify patterns and predict outcomes, informing personalized treatment plans.

Conclusions: AI has shown great potential in the diagnosis and treatment of MMD. The application of AI in treating MMD represents a promising frontier that may revolutionize clinical practices.

Objectives: To develop an accurate and easy-to-use predictive tool of short-term functional outcome for ischemic stroke patients treated with thrombolysis in the rural setting.

Methods: This multicenter retrospective study involved the Southern Illinois Healthcare rural stroke network registry as derivative cohort, and the University of Oklahoma Health Sciences Center stroke database as validation cohort. Demographics, clinical, laboratory, and radiographic data were collected. Short-term outcome at 30 days was divided in good (mRS ≤2) bad (mRS ≥5). A backward logistic regression analysis was developed by clinical significance of the dependent variables and a 5-point predictive score system was developed based on clinical plausibility and practicality. Calibration curve was designed. The score was tested on the validation cohort. P value was set at 0.05 for all statistical analyses.

Results: Of 222 patients included in the derivation cohort, 35 (16%) had poor short-term outcome. In a backward logistic regression model, baseline mRS (OR: 1.511, 95% CI: 1.047-2.182, P =0.02), and NIHSS (OR: 1.136, 95% CI: 1.063-1.214, P <0.01) were independently associated with poor short-term outcome. Age also had a strong trend toward significance (OR: 1.045, 95% CI: 0.995-1.093, P =0.05). Additional variables were re-entered in the final predictive model based on clinical plausibility and practicality. The 5-point predictive score was then created adding one point for each of the following variables: age >75, cardiac disease, baseline mRS >2, NIHSS ≥20, and GFR <40. The c-statistic of the model was 0.79, 95% CI: 0.71-0.87. In the validation cohort of 200 patients, the model performed with a c-statistic of 0.75, 95% CI: 0.64-0.86. Good outcome was predicted with a c-statistic of 0.71, 95% CI: 0.64-0.77 in the derivation cohort, and 0.69, 95% CI: 0.62-0.76 in the validation cohort.

Conclusions: This predictive score is an accurate and easy-to-use tool to help providers in the rural settings facilitate early conversations with stroke patients and their families. Providing rural settings with affordable and accurate prognostic tools is a crucial step in bridging the gap in stroke care between urban and rural settings.

Objectives: The evaluation of papilledema often requires lumbar puncture (LP) to measure opening pressure and analyze cerebrospinal fluid (CSF). However, opening pressure can be reported in different units (eg, cm H 2 O, mm Hg), and the ordering practices of CSF constituents can vary. This study aims to evaluate the pattern of opening pressure assessment and CSF laboratory ordering practices in patients with papilledema due to idiopathic intracranial hypertension (IIH).

Methods: This was a retrospective review across 3 institutions based in Houston, TX. Information was obtained for patients with optic disc edema suspected of papilledema due to IIH who presented between 2009 and 2024. Patients were included if their records contained an LP procedure note for the evaluation of papilledema. Opening pressure units and CSF constituents were recorded.

Results: A total of 227 charts were included, consisting of 317 opening pressure measurements and 245 cases with at least 1 documented CSF laboratory order. We found that units of measurement for opening pressure were reported as cm H 2 O (71%), cm (10%), no units (9%), mm H 2 O (3%), mm Hg (3%), cm CSF (2%), mm (1%), and cm/H 2 O (1%). Among the CSF samples sent for analysis, 99% included cell count, 97% included glucose, 95% included protein, 75% included culture, and 35% included additional laboratory measures.

Conclusions: Inconsistencies in LP measurement units and CSF laboratory orders may lead to misinterpretation, potentially impacting patient care for those suspected of having papilledema due to IIH. We recommend greater standardization of the assessment of LP results for those undergoing evaluation for papilledema suspected due to IIH.

Objectives: This study aims to identify retinal biomarkers of NOTCH3 mutation carriers using optical coherence tomography (OCT) data from the UK Biobank.

Methods: We conducted a cross-sectional, matched case-control study of individuals with or without NOTCH3 mutation from the UK Biobank between 2006 and 2010. All participants had macular OCT scan and cognitive assessment. Cases were identified based on pathogenic/likely pathogenic NOTCH3 mutations and 1:1 matched with controls based on age, sex, hypertension, diabetes mellitus, and cigarette smoking status. Baseline characteristics and cognitive test scores were compared using χ2 or Mann-Whitney U test appropriately. Macular thickness at central, inner, and outer subfields and at each retinal layer was compared using Wilcoxon signed-rank test.

Results: Our analysis included 134 participants (67 cases, 67 controls) with a mean age of 54 ± 9 years. NOCTH3 mutation carriers performed worse in prospective memory (P=0.043), verbal and numerical reasoning (P=0.178), visual memory (P=0.227), and processing speed (P=0.101) than matched controls. There were no differences in visual acuity between the 2 groups. NOTCH3 mutation carriers had significantly thinner macular inner subfield at the superior (P=0.006), temporal (P=0.008), and nasal (P=0.034) quadrants, and significantly thinner macular RNFL (P=0.008) compared with age-, sex-, and vascular risk factor-matched controls.

Conclusion: The presence of NOTCH3 mutation is associated with reduced thickness in the inner macular subfield and macular RFNL. These retinal changes may reflect early pericyte dysfunction and microvascular ischemia. Longitudinal studies are needed to assess the temporal relationship between these retinal changes, cerebrovascular disease progression, and clinical severity of disease.