Neurologist最新文献

Objectives: The optimal management of acute ischemic stroke (AIS) in patients with oral anticoagulation (OA) is challenging. Our study aimed to analyze the clinical characteristics and outcome of AIS in patients with OA for nonvalvular atrial fibrillation (NVAF).

Methods: We retrospectively analyzed data on NVAF patients with AIS on direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) admitted to our Stroke Unit from 2017 to 2022. Ninety-day modified Rankin Scale (mRS), 90-day, and 12-month stroke recurrences were recorded.

Results: A total of 169 patients (53.2% female, mean age 82.8±6.7 y), 117 (69.2%) on DOAC, and 52 on VKA (30.8%), were enrolled. Mean age, in-hospital mortality, and 90-day mRS ≥4 were significantly higher in VKA patients. 63.4% of VKA patients had subtherapeutic INR, whereas 47.1% of DOAC patients were on low-dose (14.2% off-label). Large vessel occlusion and embolic etiology were more frequent in VKA patients (34.6% vs. 26.4%, P =0.358; 92.3% vs. 74.3%, P =0.007, respectively), whereas lacunar strokes were more frequent in DOAC patients (19.8% vs. 12.2%, P =0.366). Among patients on VKA before AIS 86.4% were switched to DOAC, whereas a DOAC-to-VKA and a DOAC-to-DOAC switch were done in 25.4% and 11.7%, respectively. Stroke recurrence occurred in 6.4% of patients at 90 days and 10.7% at 12 months. Anticoagulant switching was not associated with stroke recurrences.

Conclusions: In our study, nonembolic etiology was more frequent in DOAC patients and anticoagulant switching did not reduce the risk of stroke recurrence. Prospective multicentric studies are warranted.

Objective: To report a case of hemicrania continua (HC) and persistent visual aura without infarction in a patient with previous episodic migraine with visual aura, whose persistent aura symptoms improved only after treatment with divalproex sodium.

Background: Once regarded as highly specific for migraine, visual aura has been associated with trigeminal autonomic cephalalgias, including HC. In previous descriptions of HC and episodes of typical visual aura, the aura occurred exclusively with severe headache exacerbations and, like the pain, resolved with indomethacin.

Methods: Case report and literature review.

Results: A 54-year-old man with a history of episodic migraine with visual aura reported a gradual onset of HC with persistent visual aura of 15 months duration. General medical and neurological examinations were normal, including imaging studies. HC's headache responded to indomethacin, while the visual aura was recalcitrant, only improving with oral divalproex sodium treatment.

Conclusion: As our patient experienced HC, which evolved from episodic migraine, we hypothesize that migraine and HC may share a common pathophysiology. However, the persistence of the visual aura, despite the abolition of pain and autonomic features with a therapeutic dose of indomethacin, and the subsequent successful treatment of the aura with divalproex sodium, suggest that aura and HC headache arise from distinct and dissociable mechanisms.

Objectives: The preferred endovascular therapy (EVT) for large-vessel occlusion in intracranial atherosclerosis (ICAS) is unknown. We compared the efficacy of preferred stent thrombectomy and preferred angioplasty in patients with acute large-vessel occlusion in ICAS.

Methods: Data from consecutive EVT patients (May 2020 to September 2023) with acute middle cerebral artery occlusion in ICAS were retrospectively analyzed. Preferred angioplasty was performed if there was a preoperative "microcatheter first-pass effect;" otherwise, preferred stent thrombectomy was performed. Analyses were grouped according to the two EVT treatments. Clinical data of all patients, including the time from puncture to recanalization, rate of successful reperfusion, early neurological improvement, intracranial hemorrhage, and modified Rankin Scale score at 90 days, were recorded and analyzed.

Results: Six-two patients were enrolled in this study (mean age was 60.66±13.21 y, 22.6% female). The preferred angioplasty group had a higher first-pass recanalization rate than the preferred stent thrombectomy group (61.3% vs. 21.9%, P <0.001) and a higher proportion of patients who were functionally independent (defined as a modified Rankin Scale score of 0 to 3) at 90 days [odds ratio,3.681; 95% confidence interval (CI):1.009 to 13.428; P =0.048]. There was no significant difference between the groups in the time from puncture to recanalization, the frequency of successful reperfusion, and early neurological improvement, or intracranial hemorrhage ( P >0.05).

Conclusions: This study suggests that for acute middle cerebral artery occlusion in ICAS, preferred angioplasty may be a safe and effective procedure.

Objectives: Whether patients with infarct volume ≥150 mL could benefit from endovascular thrombectomy (EVT) remains unclear.

Methods: Patients (n=104) with anterior circulation Alberta Stroke Program Early Computed Tomography Score <6 were screened for infarct volume ≥150 mL using the Pullicino formula × (1-22%). The following were compared with the baseline at 90 days: the modified Rankin scale score (mRS) ≤3, mortality rate, symptomatic intracranial hemorrhage and any intracranial hemorrhage within 48 hours, and modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b between the EVT and drug therapy (DT) groups.

Results: In patients with infarct volumes ≥150 mL, mRS≤3 at 90 days was higher in the EVT group than in the DT group [adjusted odds risk (aOR), 5.52; 95% CI: 1.10-28.24, P =0.04), and mTICI ≥2b at 82.8%. Intracranial hemorrhage within 48 hours occurred in 7 (24.1%) patients in the EVT group and 5 (14.7%) in the DT group (aOR, 0.75; 95% CI: 0.16-3.46; P =0.71). Older age (aOR, 0.94; 95% CI: 0.90-0.99, P =0.01), EVT treatment (aOR, 4.51; 95% CI: 1.60-12.78, P =0.01), and infarct volume ≥150 mL (aOR, 0.11; 95% CI: 0.04-0.31, P <0.01) were significantly associated with patient prognosis.

Conclusions: Patients with infarct volume ≥150 mL who received EVT had a higher proportion of mRS≤3 compared with those who received DT. However, there was no statistically significant difference in intracranial hemorrhage and death between the groups. EVT, smaller infarct volume, and younger age were associated with a good prognosis. The findings require large sample data verification.

Background and objective: West Nile neuroinvasive disease (WNND) displays a wide range of clinical manifestations due to its involvement of various structures within the central nervous system and peripheral nervous system, often including prolonged unresponsiveness as the presenting symptom.

Methods and results: We describe 2 patients presenting with coma and bilateral thalamic lesions on brain magnetic resonance imaging, found to have WNND after extensive workup. These cases illustrate some of the challenges associated with evaluating coma in general and specifically in diagnosing WNND.

Conclusion: The clinical diagnosis of WNND requires a high index of suspicion, particularly in immunocompromised and elderly patients. Brain and spine magnetic resonance imaging findings can help narrow down the differential diagnosis, although other diseases may manifest similarly. Serological studies on the cerebrospinal fluid are essential to confirm the diagnosis but have inherent limitations. Given these challenges, WNND should be considered in all patients living in endemic areas who present with unexplained altered mental status during the late summer and early fall seasons.

Objectives: To investigate the safety of administering low-dose aspirin (81 mg) 18 hours after intravenous thrombolytic therapy.

Methods: This is a retrospective cohort investigation. Individuals received either alteplase or tenecteplase for acute ischemic stroke followed by aspirin 81 mg (after follow-up imaging). An institutional change moved follow-up post-thrombolytic CT scans to 18 hours, and qualifying patients were grouped based on whether they received aspirin ≤24 hours or >24 hours. Chart reviews were conducted to assess the primary outcome of new or worsening intracranial hemorrhage, as well as secondary outcomes of change in stroke scale scores at discharge and 3 months, lengths of stay, favorable outcomes at 3 months, hospital readmission, and mortality.

Results: Out of 350 patients screened, 130 qualified for inclusion-50 of whom received aspirin ≤24 hours (mean 21.1 hours, SD±6.2), and 80 who received aspirin >24 hours (mean 34 hours, SD±8.2). Only 1 new intracranial bleed occurred following aspirin administration in the >24-hour group. No statistically significant differences were observed in any of the secondary outcomes, although there was higher mortality (3/50 vs. 2/80, P =0.372) and shorter hospital length of stay (median difference -1.0 day, P =0.0336) in the <24 hours group.

Conclusions: Low-dose aspirin administration sooner than 24 hours following thrombolytic therapy did not increase bleeding events. Sooner aspirin administration after ischemic stroke can potentially enhance the prevention of secondary embolization and did not demonstrate worse clinical outcomes; however, further randomized controlled trials are needed.

Objectives: To investigate return to work and workforce detachment in ischemic stroke, including the association with age and level of education.

Methods: Patients in the workforce aged 18 to 60 with first-time ischemic stroke between 1997 and 2017 were identified in Danish registers and followed for 5 years. The cumulative incidence of return to work and subsequent workforce detachment was computed overall and stratified according to age group and education level. Cox regression analysis was used for multivariate analysis.

Results: A total of 28,325 patients were included (median age 52.3 (interquartile range (IQR) 46.1 to 56.6) and 64.3% male). After 1 year, 62.0% were in the workforce, highest in age group 18 to 30 (80.0%) and lowest in patients aged 51 to 60 (58.5%). One-year cumulative incidence of return to work overall was 73.4% (20,475), highest in the young age group (87.0%, 76.7%, 74.5%, and 71.3% for age group 18 to 30, 31 to 40, 41 to 50, and 51 to 60, respectively) and high education (80.3%, 72.1%, and 71.3% for long higher, basic or vocational education, respectively). One-year cumulative incidence of subsequent workforce detachment was 25.6% (5248), lowest in young age (22.4%, 23.1%, 24.1%, and 27.2% for age groups 18 to 30, 31 to 40, 41 to 50, and 51 to 60, respectively) and high level of education (13.0%, 28.4%, and 27.2% for long higher, basic, and vocational education, respectively). During the full follow-up, 10,855 (53.0%) left the workforce again.

Conclusions: A high proportion of patients returned to work within 1 year, but more than half left the workforce again. Young age and long education were associated with a higher incidence of return to work and lower subsequent workforce detachment.

Objectives: To draw attention to acute positional vertigo and central positional nystagmus (CPN) developing as the sole features of cerebellar nodulus infarction.

Background: The cerebellar nodulus is vascularized by the medial branch of the posterior inferior cerebellar artery, which also supplies the uvula, tonsil, tuber, and pyramid of the vermis, and the inferior part of the cerebellar hemisphere, making isolated cerebellar nodulus infarction extremely rare. CPN occurs after a change in head position with respect to gravity and is caused by pathologies involving the vestibulo-cerebellar pathways. CPN is rarely seen in isolation. Additional neurological signs and ocular motor abnormalities are generally present.

Methods: A 62-year-old man was admitted to the emergency department with acute-onset positional vertigo and CPN as the sole finding on examination. Cranial magnetic resonance imaging revealed an acute infarction involving the nodulus. Results: Infarcts restricted to nodulus can cause positional vertigo and CPN without any associated neurological signs or ocul ar motor abnormalities.

Conclusion: Though very rare, cerebellar nodulus stroke must be searched in patients with positional vertigo of acute onset and isolated CPN on examination.

Objectives: To evaluate the relationship between Framingham Stroke Risk Profile (FSRP) score and rate of white matter hyperintensity (WMH) progression and cognition.

Methods: Consecutive patients enrolled in the Mayo Clinic Florida Familial Cerebrovascular Diseases Registry (2011-2020) with 2 brain-MRI scans at least 1 year apart were included. The primary outcome was annual change in WMH volume (cm 3 /year) stratified as fast versus slow (above vs. below median). Cognition was assessed using a Mini-Mental State Exam (MMSE, 0-30). FSRP score (0 to 8) was calculated by summing the presence of age 65 years or older, smoking, systolic blood pressure greater than 130 mmHg, diabetes, coronary disease, atrial fibrillation, left ventricular hypertrophy, and antihypertensive medication use. Linear and logistic regression analyses were performed to examine the association between FSRP and WMH progression, and cognition.

Results: In all, 207 patients were included, with a mean age of 60±16 y and 54.6% female. FSRP scores risk distribution was: 31.9% scored 0 to 1, 36.7% scored 2 to 3, and 31.4% scored ≥4. The baseline WMH volume was 9.6 cm 3 (IQR: 3.3-28.4 cm 3 ), and the annual rate of WMH progression was 0.9 cm3/year (IQR: 0.1 to 3.1 cm 3 /year). A higher FSRP score was associated with fast WMH progression (odds ratio, 1.45; 95% CI: 1.22-1.72; P<0.001) and a lower MMSE score (23.6 vs. 27.1; P<0.001). There was a dose-dependent relationship between higher FSRP score and fast WMH progression (odds ratios, 2.20, 4.64, 7.86, 8.03 for FSRP scores 1, 2, 3, and ≥4, respectively; trend P <0.001).

Conclusions: This study demonstrated an association between higher FSRP scores and accelerated WMH progression, as well as lower cognition.

Objectives: Thrombolysis treatment for patients with mild stroke is controversial. The aim of our study was to investigate the clinical characteristics and influencing factors of early neurological deterioration (END) in this group of patients.

Methods: A retrospective analysis was performed on ischemic stroke patients with intravenous thrombolysis (IVT) in Wenzhou Central Hospital. Subgroup analyses were performed for the mild stroke group and nonmild stroke group, END group, and non-early neurological deterioration group in mild stroke patients, respectively.

Results: A total of 498 patients were included in this study. Compared with the control group, the mild stroke group was younger age, less atrial fibrillation, previous history of stroke and less use of antithrombotic drugs, more dyslipidemia, smoking, and drinking. Small artery occlusion type was more common in mild stroke, cardioembolism and stroke of undetermined etiology type were less. In the mild stroke group, the symptomatic intracerebral hemorrhage (sICH) rate was 2.54%, and the END rate was 16.1%. Predictors of END included systolic blood pressure, blood glucose, cardioembolism subtype, sICH, and large vessel occlusion. In END patients, the sICH rate was 10.53%, and 84.21% of cases started to worsen within 12 hours after IVT. There was no statistically significant difference in the time to exacerbation among different subtypes.

Conclusions: The occurrence of mild stroke in young patients was largely related to unhealthy lifestyles. The incidence of END in mild stroke IVT patients was low, with most occurring within 12 hours of IVT. There were many risk factors for END: large vessel occlusion and hyperglycemia were independent risk factors for END after IVT. sICH was an important but rare risk factor for END.