Neurologist最新文献

Objectives: The indication for thrombolytic therapy in "wake-up strokes" based on diffusion-positive and FLAIR-negative lesions on MRI has been introduced in the most recent AHA/ASA stroke guidelines. While this protocol is well established in urban centers, rural hospitals often face challenges due to limited resources and the availability of MRI scanners in the emergency department (ED). Here, we report on the successful implementation of the wake-up stroke protocol within our stroke network, highlighting the planning and execution process, its safety, and outcomes.

Methods: After 2 months of planning, involving neurology, ED, radiology, and nursing leadership, the "wake-up stroke" protocol was implemented in our rural stroke network system in September 2022. Consecutive patients who received thrombolytics by the protocol were reviewed. For each patient, variables regarding demographics, relevant medical comorbidities and medications, clinical presentation, laboratory values, relevant timing of stroke metrics, complications of thrombolytic therapy, and mRS at 30 days were collected. The group was compared with a randomly severity-matched group of patients who received thrombolytic therapy by standard treatment (within 4.5 h from last known well).

Results: Five consecutive acute ischemic stroke patients treated with thrombolytic therapy were identified. Mean age ± SD was 71.2 ± 7.2 years. Of the patients, 60% were males (n = 3). The most common reason for unknown time of symptom onset was nighttime sleep in 60% (n = 3) of the cohort. The median NIHSS (IQR) was 7 (6 to 13). Of the patients, 60% (n = 3) had a M2 occlusion on MR angiogram. The median interval between LKW and needle treatment was 11.68 (IQR: 5.32 to 13.23) hours. Compared with standard treatment, the wake-up stroke group had similar rate of complications (none in each group) and similar rate of mRS <2 at 1 month (60% vs 80%, P = 0.49).

Conclusions: The implementation of the wake-up stroke protocol in our network was feasible, with the safety and outcomes of thrombolytics delivered by the protocol comparable to standard treatment. This study supports the utilization of the wake-up stroke protocol in real-world rural practice, highlighting its potential to improve access to high-quality stroke care in underserved areas.

Objective: Cervical artery dissection (CeAD) was previously thought to be more common in men, but recent epidemiology studies show a disproportionate increase in the incidence of CeAD in women. In addition to sex-based differences in clinical presentation, there are unique biological risk factors for CeAD in women. Identifying risk factors for ischemic stroke in CeAD is crucial in individualizing treatment options. Herein, we utilized an inpatient cohort to investigate whether noncancerous gynecologic conditions or pregnancy are risk factors for ischemic stroke in CeAD.

Methods: The National Inpatient Sample was queried from 2016 to 2020 for patients diagnosed with CeAD using the International Classification of Diseases, 10th edition, correction of the mean codes. Diagnoses of pregnancy/puerperium and noncancerous gynecologic conditions were identified. Among CeAD admissions, acute ischemic stroke (AIS) was also identified. Hierarchical, multivariable regression, adjusted for patient demographics and medical comorbidities, was conducted to assess factors associated with AIS.

Results: A total of 34,925 women with CeAD were identified. Of these women, 2.1% were pregnant or up to six weeks postpartum, 1.3% had a noncancerous gynecologic condition, and 0.09% had both active pregnancy/puerperium and a noncancerous gynecologic condition. Noncancerous gynecologic conditions (odds ratio = 1.86, P = 0.012) were found to be an independent risk factor for AIS in CeAD but not active pregnancy/puerperium (odds ratio = 0.84, P = 0.34).

Conclusion: In this national inpatient sample of female patients with CeAD, the presence of noncancerous gynecologic conditions is associated with an increased risk of AIS. Further studies are needed to validate this observation and help guide the best antithrombotic treatment decisions in this patient population.

Objectives: Our purpose is to assess the role of total small vessel disease (SVD) burden affecting the clinical outcome and develop and validate a prognostic nomogram for minor ischemic stroke (MIS) patients.

Methods: Between January 2018 and April 2023, 454 MIS patients were enrolled. The functional outcome was the modified Rankin scale (mRS) score at 90 days. The least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression model were used to identify prognostic predictors, and then a nomogram was drawn.

Results: Our nomogram comprising of systolic blood pressure (SBP), baseline National Institutes of Health Stroke Scale score (NIHSS), total SVD burden scores, coronary heart disease, disabling stroke, progressive stroke, alteplase treatment, and infarction location demonstrated a good discriminative power in both the training set (AUC=0.870; 95% CI: 0.827-0.912) and the internal validation set (AUC=0.876; 95% CI: 0.817-0.935). The calibration curve and DCA in our result showed the model's high degree of calibration and clinical value. The DeLong test was used to compare the AUCs between the nomogram and non-SVD burden score model in the training ( P =0.028) and internal validation sets ( P =0.013), indicating that our nomogram performs significantly better than the non-SVD burden score model.

Conclusions: The SVD burden is an important prognosis factor. Furthermore, the proposed nomogram has good discrimination, calibration, and clinical benefits and is better than the non-SVD burden score model in predicting the outcomes for MIS patients.

Introduction: Although primarily supplied by the vertebrobasilar system, the hippocampus is partially supplied by ipsilateral carotid artery branches through the anterior choroidal artery or a prominent posterior communicating artery. We report a patient with acute hippocampus infarction likely due to symptomatic ipsilateral tandem carotid stenosis and discuss acute vascular-mediated hippocampal injury.

Case report: An 80-year-old female with obesity, dyslipidemia, hypertension, alcohol use disorder, history of breast cancer on letrozole, and traumatic brain injury was brought into our emergency department for 24 hours of confusion. On examination, she exhibited limited registration, recall, and executive dysfunction with otherwise normal language, visuo-spatial orientation, and praxis. Brain MRI showed a small area of diffusion restriction in the anterior right hippocampus with matched FLAIR hyperintensity, consistent with acute infarction. Computed tomography angiogram head and neck showed 90% stenosis of the proximal right internal carotid artery (ICA), <50% narrowing of the proximal left ICA, and moderate bilateral narrowing of the paraclinoid ICAs, all due to calcific atheromatous plaques. The etiology of the hippocampal infarction was suspected embolism from the ipsilateral severe carotid stenosis. Planning for right cervical carotid revascularization ensued.

Conclusion: This case highlights the dual hippocampal vascular supply and that hippocampal embolic infarcts could be a sign of a symptomatic severe carotid artery stenosis that may require urgent revascularization for stroke secondary prevention.

Objective: Cerebral infarction (CI) is a prevalent and frequently occurring condition. However, the association between expansive remodeling in the carotid artery system and CI is still uncertain. This study aims to investigate the significance of the carotid artery system and aortic arch (AA) remodeling for the prevention and treatment of CI.

Methods: We collected data from 821 patients who underwent computed tomography angiography at our hospital, performed statistical analysis, and compared it with various clinical data.

Results: We found that the diameters and detection rates of the common carotid artery (CCA), internal carotid artery (ICA), carotid bifurcation, and AA were significantly greater in the CI group than in the without CI group ( P <0.05). The number of carotid sinus plaque (CSP) and the length of aortic arch plaque (AAP) were considered to be 2 important factors in predicting CCA remodeling. Moreover, the thickness of AAP was considered to be an important factor in predicting AA remodeling.

Conclusions: Patients with CI exhibited a significant increase in the diameter of the carotid system and AA, which correlated with certain features of arterial plaque. Hence, early detection of arterial plaques, along with interventions to delay or potentially reverse expansive arterial remodeling, may be effective in preventing and treating CI.

Introduction: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common hereditary cerebral small vessel disease with slow natural progression. Ischemic stroke and cognitive impairment are its most common clinical symptoms. Here, we report a rare 50-year-old woman who had rapid disease progression with c.457C>T, p.Argl53Cys heterozygous mutation in exon 4 of NOTCH3 and discuss the possible reasons. Furthermore, we summarized the clinical and neuroimaging characteristics of 14 CADASIL patients with Arg153Cys mutation in exon 4.

Case report: The proband suffered acute ischemic stroke 5 times in 5 months, followed by rapidly progressive dementia (RPD) and inability to live independently, though she didn't have vascular risk factors and had been under standardized secondary prevention therapy since the first stroke. Magnetic resonance imaging showed extensive white matter hyperintensities, numerous ischemic infarcts and microbleeds, and severe brain atrophy. Her elder brother and other patients with Arg153Cys mutation in exon 4 all did not progress so quickly. Her multiple strokes may be associated with the poor self-regulation of vessels, which may promote the occurrence of RPD. Antiplatelet and anticoagulant drugs were difficult to prevent ischemic strokes. Severe imaging findings may indicate rapid progression of CADASIL. In addition, we found that headache was a very frequent symptom in CADASIL patients with Arg153Cys mutation in exon 4, accounting for 76.9%.

Conclusions: CADASIL can also appear to have rapid progression, as illustrated by our proband, which is worthy of clinicians' attention and intervention timely. Headache may present in a relatively higher proportion of CADASIL patients with Arg153Cys mutation in exon 4.

Objective: This research aimed to ascertain the effects of tirofiban combined with thrombus aspiration and stent thrombectomy on large vessel occlusion ischemic stroke (LVO-IS).

Methods: Sixty patients with acute ischemic stroke (AIS) caused by LVO were randomized into the control group and the intervention group (n=30). Patients in the control group received thrombus aspiration combined with stent thrombectomy, while those in the intervention group were treated with tirofiban combined with thrombus aspiration and stent thrombectomy. General data, perioperative-related indicators, cerebral blood flow perfusion, coagulation function indicators, and neurological function indicators were collected, and the prognosis was observed after 3-month treatment.

Results: A comparison of symptomatic cerebral hemorrhage rate and hospital mortality rate between the 2 groups displayed no significant difference ( P >0.05). The rate of revascularization in the intervention group (90.00%) was higher versus the control group (66.67%). After treatment, the mean blood flow and cerebral blood volume of the intervention group were higher and the time to peak cerebral blood flow was less versus the control group. The prothrombin time, activated partial thromboplastin time, and prothrombinogen time of the intervention group were higher, and fibrinogen was lower versus the control group. A lower National Institutes of Health Stroke Scale score was observed in the intervention group versus the control group.

Conclusions: Tirofiban combined with thrombus aspiration and stent thrombectomy has good efficacy in LVO-IS patients.

Objectives: Early clinical worsening (ECW) in acute isolated pontine infarcts (AIPI) is frequent, associated with poor prognosis, and its predictors have not been adequately clarified. A possible role of dolichoectatic basilar artery (BA) anatomy in ECW in patients with AIPI is herein studied.

Methods: In 146 AIPI patients, infarcts were grouped into tegmental, lateral, anterolateral, anteromedial horizontally; and low, mid, mid-up, and upper pontine vertically. BA dolichoectasia was categorized according to Smoker criteria. An additional criteria of BA laterality angle was described. The length between the infarct long-axis and BA cross-sectional center was measured, and named as "branch length (BL)." ECW was defined as any increase in NIHSS.

Results: ECW was seen in 22 (15%) patients. Univariate analysis documented a higher female ratio (22% vs. 10%, P =0.007), higher atrial fibrillation (18% vs. 7%, P =0.067), more common anteromedial infarct location (77% vs. 49%, P =0.025), and Smoker category-3 BA height (32% vs. 10%, P =0.043) in these patients. In anteromedial infarcts, BL was longer (8.3 vs. 6.1 mm, P =0.052), and reaching to significance in those located at mid-up/upper pontine level (1.22 vs. 0.62 mm, P =0.006). BL >4.4 mm showed an acceptable discriminatory capacity for ECW with an AUC of ROC: 0.615 (95% CI: 0.511-0.712). A regression model indicated female sex (β±SE=1.129±0.551, P =0.040), BL (per 4.4 mm, β±SE=1.236±0.614, P =0.044), and BA height-category-3 (β±SE=1.711±0.645, P =0.008) as independent predictors for ECW.

Conclusions: Some features of basilar dolichoarteriopathy, such as the extreme location of the height of the BA tip and the length of the involved perforator in the prepontine cistern, may be predictors of early clinical worsening in acute isolated pontine infarcts.

Objectives: Neurological emergencies pose significant challenges in medical care in resource-limited countries. Artificial intelligence (AI), particularly health chatbots, offers a promising solution. Rigorous validation is required to ensure safety and accuracy. Our objective is to evaluate the diagnostic safety and effectiveness of an AI-powered virtual assistant (VA) designed for the triage of neurological pathologies.

Methods: The performance of an AI-powered VA for emergency neurological triage was tested. Ten patients over 18 years old with urgent neurological pathologies were selected. In the first stage, 9 neurologists assessed the safety of the VA using their clinical records. In the second stage, the assistant's accuracy when used by patients was evaluated. Finally, VA performance was compared with ChatGPT 3.5 and 4.

Results: In stage 1, neurologists agreed with the VA in 98.5% of the cases for syndromic diagnosis, and in all cases, the definitive diagnosis was among the top 5 differentials. In stage 2, neurologists agreed with all diagnostic parameters and recommendations suggested by the assistant to patients. The average use time was 5.5 minutes (average of 16.5 questions). VA showed superiority over both versions of ChatGPT in all evaluated diagnostic and safety aspects ( P <0.0001). In 57.8% of the evaluations, neurologists rated the VA as "excellent" (suggesting adequate utility).

Conclusions: In this study, the VA showcased promising diagnostic accuracy and user satisfaction, bolstering confidence in further development. These outcomes encourage proceeding to a comprehensive phase 1/2 trial with 100 patients to thoroughly assess its "real-time" application in emergency neurological triage.