Neurologist最新文献

Background: Radiologically Isolated Syndrome (RIS) is defined as incidentally found MRI abnormalities that are radiographically indistinguishable from multiple sclerosis (MS) and is considered a presymptomatic disease state of MS. Age <37 years, infratentorial or spinal cord lesions, gadolinium-enhancing lesions on index imaging, and positive cerebrospinal fluid oligoclonal bands have been identified as risk factors for conversion to MS. There are no existing guidelines regarding the role of disease-modifying therapy (DMT) in RIS patients.

Objective: The objective of this study was to critically assess the current evidence regarding the impact of initiating DMT for patients with RIS on the time to first clinical attack of MS.

Methods: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, medical librarian, and content experts in the field of neuroimmunology.

Results: A multicenter, prospective, randomized, double-blind, placebo-controlled trial was chosen for critical appraisal. This trial examined the impact of treatment with dimethyl fumarate (DMF) versus placebo on the risk of conversion from RIS to MS over a 96-week study period. Patients in the DMF arm were found to have an 82% reduction in risk of clinical attack. DMF patients also had a smaller number of new/newly enlarging T2 hyperintense lesions compared with placebo. No subgroup analyses were performed to elucidate risk factors for conversion.

Conclusions: While initiation of DMT in RIS does appear to reduce the time to first clinical attack of MS, the risk factors that should prompt initiation of DMT in this patient population require further study.

Introduction: Acute ischemic stroke (AIS) is one of the leading causes of morbidity and mortality in adults worldwide. Intravenous injection of recombinant tissue plasminogen activator is an established and effective treatment for AIS patients. The most common adverse effects of alteplase are hemorrhagic complications.

Case report: In this report, we highlight a rare but severe complication-primary fibrinolysis-following alteplase administration. A 68-year-old man without any cardiocerebral vascular diseases presented with the sudden onset of hemiplegia on the right. The initial National Institutes of Health Stroke Scale (NIHSS) score was 3, consisting of motor dysfunction in the right upper limb (score of 1) and lower limb (score of 2). Brain computed tomography (CT) revealed no evidence of hemorrhage. We conducted a standard dose of intravenous alteplase (IVT) for this patient. However, the patient had a terrible fibrinolytic system with extremely low fibrinogen after 8 hours of IVT (FIB <0.01, Clauss method). Immediate administration of 10 units of cryoprecipitate restored coagulation function, with significant improvement observed within 48 hours.

Conclusion: This case underscores the importance of vigilant coagulation monitoring in AIS patients undergoing alteplase therapy. Furthermore, infusion of cryoprecipitate for these patients indicated obvious therapeutic effects.

Introduction: Ten patients with thalamic infarction caused by moderate-to-severe posterior cerebral artery (PCA) stenosis confirmed by computed tomography angiography (CTA) were enrolled. To better assess the vascular pathology, high-resolution magnetic resonance imaging (HRMRI) was subsequently used to evaluate the PCA in detail. In addition, we retrospectively analyzed clinical features, treatments, and prognostic outcomes.

Case report: Ten patients were included, 7 males and 3 females, with an average age of 67.8±6.6 years. Past history includes: smoking (50%), drinking (30%), hypertension (70%), diabetes mellitus (40%), hyperlipidemia (10%), and cerebral infarction (10%). Clinical manifestations include sensory disorders (60%), motor disorders (50%), cognitive and consciousness disorders (10%), and language impairment (20%). HRMRI suggested that the PCA was moderately or severely stenosed in 4 cases, mildly stenosed in 5 cases, and normal in 1 case. It also suggested the presence of PCA atherosclerotic plaques in 9 patients.

Conclusion: Antiplatelet therapy proves effective for this patient population. HRMRI identified atherosclerotic plaques mainly in the PCA's P1 and P2 segments. P1 stenosis often impairs consciousness, while P2 stenosis typically causes sensory/motor deficits. HRMRI aids in evaluating stenosis and plaque features for diagnosis and treatment guidance.

Objective: To explore the effects of Intermittent Theta Burst Stimulation (iTBS) on the posterior inferior frontal gyrus of the left hemisphere on the expression function of patients with aphasia after stroke, and to explore the specific mechanism of fractional amplitude of low-frequency fluctuation (fALFF) analysis and degree centrality (DC) analysis of resting-state functional MRI.

Methods: According to the inclusion and exclusion criteria, 40 patients with poststroke aphasia were randomized into a treatment group (iTBS group) and a control group (S-iTBS group). Patients in the iTBS group received iTBS +speech training, and patients in the S-iTBS group received sham iTBS + speech training. The Western aphasia test (Chinese version) was used to assess spontaneous language, naming, retelling, and aphasia quotient before and after treatment; resting-state fMRI scans were performed before and after treatment, and the scanned image data were analyzed to explore specific activated or suppressed brain regions.

Results: Compared with before and after treatment, the scores of spontaneous language, naming, retelling, and aphasia quotient of the patients in iTBS group improved significantly, and the spontaneous language, naming, retelling, and aphasia quotient of the patients in S-iTBS group also improved. After the treatment, the scores of naming, retelling and aphasia quotient of the patients in the iTBS group improved significantly compared with that of the patients in the S-iTBS group. The resting-state fMRI results of the 2 groups before and after treatment were fALFF analysis found that the fALFF value increased in multiple brain regions in the left frontal and temporal lobes of the patients in iTBS group. Meanwhile, DC analysis also found increased DC values in multiple frontotemporal brain regions of the left hemisphere of patients in the iTBS group, indicating that the improved activation of the above brain regions of the patients in the iTBS group was significantly compared with that of the patients in the S-iTBS group.

Conclusions: iTBS combined with conventional speech training significantly improved the expression function of patients with aphasia after stroke. After iTBS action on the left hemisphere, increased activation of multiple brain regions in the left hemisphere may be one of the important mechanisms by which iTBS improves expression function in poststroke aphasia patients.

Introduction: Dystonic hand postures are uncommon in patients with frontal lobe infarction. Here, we report the first case of a patient with frontal lobe infarction presenting with unique dystonic hand postures-specifically, a pointing gun posture and full-finger extension posture-in combination with frontal release signs.

Case report: A 68-year-old man with a prior diagnosis of probable Parkinson disease acutely developed speech and communication impairment, along with reduced voluntary motor function in the right lower extremity. Neurological examination revealed apathy, motor and sensory aphasia, and flaccid paralysis of the right lower limb. Brain magnetic resonance imaging showed an ischemic stroke involving the left superior frontal gyrus, cingulate gyrus, and corpus callosum. Dopamine transporter single-photon emission computed tomography revealed reduced tracer accumulation in the left striatum. Ten days after stroke onset, the patient exhibited a pointing gun posture in the right hand. A repeat neurological examination revealed a grasp reflex. Removing grasped objects led to a transient index finger extension with flexion of the other fingers or a transient full extension of all fingers. The former resembled a pointing gun posture, while the latter, a newly described phenomenon, was termed the full-finger extension posture. In addition, groping movements with the pointing gun posture were observed.

Conclusion: Atypical frontal release signs, including the pointing gun posture and full-finger extension posture, may reflect specific thalamocortical excitation resulting from a combination of contralateral striatal dopaminergic denervation and frontal lobe infarction involving the supplementary motor area.

Introduction: Thalamic infarctions represent a rare subset of ischemic strokes, characterized by a diverse array of clinical manifestations and significant diagnostic challenges. These infarctions can lead to a wide range of neurological deficits, depending on the specific vascular territory involved. Infarctions within the posterior circulation territory of P2, particularly those affecting the inferolateral and posterior choroidal arteries, are associated with distinct neurological symptoms, including contralateral sensory loss, hemiparesis, hemiataxia, thalamic hand, and various sensory and motor disturbances.

Case report: We present the case of a 47-year-old woman with a unilateral thalamic infarction involving occlusion of the P2 branch of the posterior cerebral artery. The infarction, caused by a paradoxical embolism secondary to a high-grade patent foramen ovale (PFO) with an interatrial septal aneurysm, occurred in the absence of classic vascular risk factors. The patient exhibited a clinical syndrome consistent with ischemic lesions in the inferolateral and posterior choroidal arteries, manifesting as right-sided hemiparesthesia, hemiataxia with neuropathic pain, thalamic hand, dystonia, and tremor in the upper right limb.

Conclusion: Early and precise clinical identification of thalamic infarctions, especially in rare cases involving multiple vascular territories, is essential for improving patient care and outcomes. Recognizing the spectrum of potential symptoms facilitates effective symptom management, minimizes the risk of secondary complications, and optimize neurological rehabilitation.

Objectives: This study aimed to evaluate the incidence and risk factors of urinary retention in acute ischemic stroke (AIS) patients.

Materials and methods: A total of 993 patients diagnosed with AIS were analyzed retrospectively. According to the incidence of urinary retention, these patients were divided into the urinary retention group and the nonurinary retention group. The incidence of urinary retention after AIS was analyzed. Univariate analysis and binary logistic regression analysis were performed to screen the independent risk factors for urinary retention after AIS.

Results: The incidence of urinary retention in AIS patients was 10.98% (109/993). According to the results of the univariate analysis, age ( P <0.01), sex ( P =0.020), National Institutes of Health Stroke Scale (NIHSS) <10 ( P <0.01), Barthel Index (BI) <40 ( P <0.01), multiple cerebral infarction ( P =0.002), manual muscle test (MMT) ( P <0.01), urinary tract infection (UTI) ( P <0.01), and benign prostate hyperplasia (BPH) ( P <0.01) were significantly correlated with urinary retention incidence. The binary logistic regression analysis revealed that female (OR: 1.954, 95% CI: 1.065-3.587), BI <40 (OR: 24.067, 95% CI: 11.652-49.713), UTI (OR: 8.214, 95% CI: 3.714-18.169), and BPH (OR: 11.342, 95% CI: 5.460-12.560) were independent risk factors for urinary retention after AIS.

Conclusions: The incidence of urinary retention in AIS patients was 10.98%. BI <40, UTI, and BPH were identified as risk factors for poststroke urinary retention. In addition, being female constituted another risk factor for urinary retention, requiring further study.

Objective: Our study explores the relationship between fasting triglyceride levels and initial infarct volume in acute ischemic stroke (AIS) patients.

Methods: We performed a retrospective chart review and cross-sectional analysis of AIS patients admitted to a tertiary care center in Kansas from 2010 to 2023. Inclusion criteria were AIS patients who (1) underwent CTA and CTP within 24 hours of stroke onset, and (2) had fasting triglyceride levels measured within 24 hours of admission. Infarct volume was calculated using RAPID software (iSchemaView Inc.). Statistical analyses were conducted using STATA (Release 16), with T tests, ANOVA, χ 2 tests, and multivariable linear regression applied as appropriate.

Results: We included 178 patients, 52% (n=92) of whom were male, and 31% were aged 61 to 70 years. Mean TG levels were 116.91±70.23 mg/dL, and mean infarct volume was 41.64±53.35 mL. Linear regression showed a significant positive association between TG levels and infarct volume ( P <0.01, β=0.17, 95% CI: 0.06-0.28), with a 0.17 mL increase in infarct volume per unit increase in TG levels. Patients with Embolic stroke of undetermined source (ESUS) had larger infarct volumes compared with those with large artery atherosclerosis ( P <0.05) and the highest mean TG levels (135.61 mg/dL).

Conclusion: Hypertriglyceridemia was positively associated with larger infarct volumes, particularly in ESUS patients, who had the highest TG levels and larger infarct sizes. These findings suggest that elevated TG may predict worse stroke outcomes and could be a potential therapeutic target for stroke prevention.

Background: Stroke-associated pneumonia (SAP), a highly lethal complication following stroke, is closely linked to dysregulation of the "brain-gut-lung axis." Accumulating evidence indicates that stroke triggers intestinal alterations through the brain-gut axis, while multiple studies confirm that gut-derived changes can mediate pneumonia through the gut-lung axis. However, the mechanisms connecting stroke-induced intestinal dyshomeostasis to SAP remain incompletely elucidated, and the multiorgan interaction mechanisms of the "brain-gut-lung axis" in SAP pathogenesis require further exploration.

Review summary: This systematic literature review systematically searched databases, including PubMed, using the keywords "stroke," "gastrointestinal microbiome," and "bacterial pneumonia," incorporating 80 mechanistic studies. Key findings reveal that stroke initiates a cascade of "neuro-microbial-immune" pathway interactions along the brain-gut-lung axis, leading to intestinal dyshomeostasis characterized by microbiota and metabolite alterations, barrier disruption, immune dysregulation, inflammatory responses, and impaired gut motility. These intestinal perturbations ultimately disrupt pulmonary immune homeostasis, promoting SAP development. In addition, stroke directly induces vagus nerve injury through the brain-gut axis, resulting in impaired swallowing and cough reflexes that exacerbate aspiration-related pulmonary infection risks.

Conclusions: Elucidating the role of the brain-gut-lung axis in SAP pathogenesis provides critical insights into its underlying mechanisms. This paradigm highlights intestinal homeostasis modulation and vagus nerve stimulation as promising therapeutic strategies for SAP prevention and management, advancing a multitargeted approach to mitigate poststroke complications.

Objectives: Minor strokes are defined as ischemic cerebrovascular accidents that present with mild symptoms scoring ≤5 on the National Institute of Health Stroke Scale (NIHSS). We aimed to investigate whether features related to stroke characteristics, location, severity, or symptoms could predict the risk of disability after minor strokes.

Methods: Minor strokes (105) were divided into 2 subgroups: those with baseline NIHSS ≤3 and those with baseline NIHSS 4-5. Comorbidities, occurrence of disability, stroke location, etiology, and outcomes were examined in the 2 subgroups and in those who developed a modified Rankin scale (mRs) of 0 to 1 or mRs >1.

Results: No-IVT minor strokes in the NIHSS 4-5 subgroup were associated with more disability compared with the NIHSS ≤3 subgroup ( P >0.05). Residual disability (mRS >1) was associated with a higher incidence of posterior circulation strokes (PCS) ( P =0.0015), large vessel stenosis ( P =0.01), and PCS-related symptoms (imbalance, gait ataxia, and eye movement disorders) not accounted for by NIHSS, in strokes with baseline NIHSS ≤3. Disability (mRS >1) was associated with baseline disabling symptoms, which NIHSS effectively and reliably captured in patients with stroke with NIHSS 4-5.

Conclusions: Symptoms that might predict unfavorable outcomes are not well captured by the available clinical instruments that are usually used to evaluate and score acute ischemic stroke at onset. When deciding on the management of minor stroke, clinicians must consider and judge all potentially disabling deficits, in addition to the pure scores of the adopted evaluation scales.