Corrigendum: How often is occult atrial fibrillation in cryptogenic stroke causal vs. incidental? A meta-analysis.

[This corrects the article DOI: 10.3389/fneur.2023.1103664.].

How often is occult atrial fibrillation in cryptogenic stroke causal vs. incidental? A meta-analysis.

Introduction: Long-term cardiac monitoring studies have unveiled low-burden, occult atrial fibrillation (AF) in some patients with otherwise cryptogenic stroke (CS), but occult AF is also found in some individuals without a stroke history and in patients with stroke of a known cause (KS). Clinical management would be aided by estimates of how often occult AF in a patient with CS is causal vs. incidental. Methods: Through a systematic search, we identified all case-control and cohort studies applying identical long-term monitoring techniques to both patients with CS and KS. We performed a random-effects meta-analysis across these studies to determine the best estimate of the differential frequency of occult AF in CS and KS among all patients and across age subgroups. We then applied Bayes' theorem to determine the probability that occult AF is causal or incidental. Results: The systematic search identified three case-control and cohort studies enrolling 560 patients (315 CS, 245 KS). Methods of long-term monitoring were implantable loop recorder in 31.0%, extended external monitoring in 67.9%, and both in 1.2%. Crude cumulative rates of AF detection were CS 47/315 (14.9%) vs. KS 23/246 (9.3%). In the formal meta-analysis, the summary odds ratio for occult AF in CS vs. KS in all patients was 1.80 (95% CI, 1.05-3.07), p = 0.03. With the application of Bayes' theorem, the corresponding probabilities indicated that, when present, occult AF in patients with CS is causal in 38.2% (95% CI, 0-63.6%) of patients. Analyses stratified by age suggested that detected occult AF in patients with CS was causal in 62.3% (95 CI, 0-87.1%) of patients under the age of 65 years and 28.5% (95 CI, 0-63.7%) of patients aged 65 years and older but estimates had limited precision. Conclusion: Current evidence is preliminary, but it indicates that in cryptogenic stroke when occult AF is found, it is causal in about 38.2% of patients. These findings suggest that anticoagulation therapy may be beneficial to prevent recurrent stroke in a substantial proportion of patients with CS found to have occult AF.

Mycotic aneurysm.

Angioinvasive fungal infections of the cerebral vasculature often lead to significant morbidity and mortality. High clinical suspicion and early antifungal therapy could improve outcomes. We describe the fatal case of a patient with a rapidly enlarging cavernous carotid aneurysm due to angioinvasive fungus. This case highlights the challenges in diagnosis and management of this condition.

Incidence and Predictive Factors Associated with Beta-Lactam Neurotoxicity in the Critically Ill: A Retrospective Cohort Study.

BACKGROUND: Beta-lactam neurotoxicity is a relatively uncommon yet clinically significant adverse effect in critically ill patients. This study sought to define the incidence of neurotoxicity, derive a prediction model for beta-lactam neurotoxicity, and then validate the model in an independent cohort of critically ill adults. METHODS: This retrospective cohort study evaluated critically ill patients treated with ≥ 48 h of cefepime, piperacillin/tazobactam, or meropenem. Two separate cohorts were created: a derivation cohort and a validation cohort. Patients were screened for beta-lactam neurotoxicity by using search terms and diagnosis codes, followed by clinical adjudication using a standardized adverse event scoring tool. Multivariable regression models and least absolute shrinkage and selection operator were used to identify surrogates for neurotoxicity and develop a multivariable prediction model. RESULTS: The overall incidence of beta-lactam neurotoxicity was 2.6% (n/N = 34/1323) in the derivation cohort and 2.1% in the validation cohort (n/N = 16/767). The final multivariable neurotoxicity assessment tool included weight, Charlson comorbidity score, age, and estimated creatinine clearance as predictors of neurotoxicity. Incidence of neurotoxicity reached 4% in those with a body mass index more than 30 kg/m2. Use of the candidate variables in the neurotoxicity assessment tool suggested that a score more than 35 would identify a patient at high risk for neurotoxicity with 75% sensitivity and 54% specificity. CONCLUSIONS: In this single center cohort of critically ill patients, beta-lactam neurotoxicity was demonstrated less frequently than previously reported. We identified obesity as a novel risk factor for the development of neurotoxicity. The prediction model needs to be further refined before it can be used in clinical practice as a tool to avoid drug-related harm.

Professional actors demonstrate variability, not stereotypical expressions, when portraying emotional states in photographs.

It is long hypothesized that there is a reliable, specific mapping between certain emotional states and the facial movements that express those states. This hypothesis is often tested by asking untrained participants to pose the facial movements they believe they use to express emotions during generic scenarios. Here, we test this hypothesis using, as stimuli, photographs of facial configurations posed by professional actors in response to contextually-rich scenarios. The scenarios portrayed in the photographs were rated by a convenience sample of participants for the extent to which they evoked an instance of 13 emotion categories, and actors' facial poses were coded for their specific movements. Both unsupervised and supervised machine learning find that in these photographs, the actors portrayed emotional states with variable facial configurations; instances of only three emotion categories (fear, happiness, and surprise) were portrayed with moderate reliability and specificity. The photographs were separately rated by another sample of participants for the extent to which they portrayed an instance of the 13 emotion categories; they were rated when presented alone and when presented with their associated scenarios, revealing that emotion inferences by participants also vary in a context-sensitive manner. Together, these findings suggest that facial movements and perceptions of emotion vary by situation and transcend stereotypes of emotional expressions. Future research may build on these findings by incorporating dynamic stimuli rather than photographs and studying a broader range of cultural contexts.

Acute Epstein-Barr virus infection presenting as Guillain-Barre syndrome.

An 18-year-old man presented with 5-days of a lower extremity rash, sore throat, rapidly progressive bilateral facial numbness and paresthesias in his distal extremities. His neurological examination acutely deteriorated to include moderate bilateral facial weakness in a lower motor neuron pattern, mild flaccid dysarthria, mild bilateral interossei weakness, and diffuse hyporeflexia. In addition to neurological examination, EMG results of acute demyelinating polyradiculoneuropathy were suggestive of Guillain-Barre Syndrome (GBS). Infectious laboratory testing demonstrated acute infection of Epstein-Barr Virus (EBV) with relatively low EBV DNA quantitative values. The patient subsequently developed fever and cervical lymphadenopathy during his hospital course. Contrasting typical GBS, which presents weeks after an acute infection, the patient's presenting symptom of EBV infection was GBS. GBS as a presenting symptom of EBV has not previously been described. This case may represent a unique mechanism for the pathogenesis of GBS in acute infections as opposed to the traditional post-infectious antibody-mediated process.

Implications for Emotion: Using Anatomically Based Facial Coding to Compare Emoji Faces Across Platforms.

Emoji faces, which are ubiquitous in our everyday communication, are thought to resemble human faces and aid emotional communication. Yet, few studies examine whether emojis are perceived as a particular emotion and whether that perception changes based on rendering differences across electronic platforms. The current paper draws upon emotion theory to evaluate whether emoji faces depict anatomical differences that are proposed to differentiate human depictions of emotion (hereafter, "facial expressions"). We modified the existing Facial Action Coding System (FACS) (Ekman and Rosenberg, 1997) to apply to emoji faces. An equivalent "emoji FACS" rubric allowed us to evaluate two important questions: First, Anatomically, does the same emoji face "look" the same across platforms and versions? Second, Do emoji faces perceived as a particular emotion category resemble the proposed human facial expression for that emotion? To answer these questions, we compared the anatomically based codes for 31 emoji faces across three platforms and two version updates. We then compared those codes to the proposed human facial expression prototype for the emotion perceived within the emoji face. Overall, emoji faces across platforms and versions were not anatomically equivalent. Moreover, the majority of emoji faces did not conform to human facial expressions for an emotion, although the basic anatomical codes were shared among human and emoji faces. Some emotion categories were better predicted by the assortment of anatomical codes than others, with some individual differences among platforms. We discuss theories of emotion that help explain how emoji faces are perceived as an emotion, even when anatomical differences are not always consistent or specific to an emotion.

Lacosamide Pharmacokinetics in a Critically Ill Patient During Continuous Renal Replacement Therapy.

The objective of this study is to describe the pharmacokinetics of lacosamide in a critically ill adult during continuous venovenous hemofiltration (CVVH). A 78-year-old male developed sepsis and acute kidney injury following cardiac surgery. He was initially treated with intermittent hemodialysis but developed nonconvulsive status epilepticus at the end of the first session and was subsequently initiated on CVVH. In addition to lorazepam boluses, levetiracetam, and midazolam infusion, he was loaded with lacosamide 400 mg intravenously and started on 200 mg intravenously twice daily as maintenance therapy. Noncompartmental modeling of lacosamide pharmacokinetics revealed significant extracorporeal removal, a volume of distribution of 0.69 L/kg, elimination half-life of 13.6 hours, and peak and trough concentrations of 7.4 and 3.7 mg/L, respectively (goal trough, 5-10 mg/L). We found significant extracorporeal removal of serum lacosamide during CVVH, which was higher than previously reported. This led to subtherapeutic concentrations and decreased overall antiepileptic drug exposure. The relationship between serum lacosamide concentrations and clinical efficacy is not well understood; thus, therapeutic drug monitoring is not routinely recommended. Yet, we demonstrated that measuring serum lacosamide concentrations in the critically ill population during continuous renal replacement therapy may be useful to individualize dosing programs. Further pharmacokinetic studies of lacosamide may be necessary to generate widespread dosing recommendations.

What Color Is Your Anger? Assessing Color-Emotion Pairings in English Speakers.

Do English-speakers think about anger as "red" and sadness as "blue"? Some theories of emotion suggests that color(s)-like other biologically-derived signals- should be reliably paired with an emotion, and that colors should differentiate across emotions. We assessed consistency and specificity for color-emotion pairings among English-speaking adults. In study 1, participants (n = 73) completed an online survey in which they could select up to three colors from 23 colored swatches (varying hue, saturation, and light) for each of ten emotion words. In study 2, different participants (n = 52) completed a similar online survey except that we added additional emotions and colors (which better sampled color space). Participants in both studies indicated the strength of the relationship between a selected color(s) and the emotion. In study 1, four of the ten emotions showed consistency, and about one-third of the colors showed specificity, yet agreement was low-to-moderate among raters even in these cases. When we resampled our data, however, none of these effects were likely to replicate with statistical confidence. In study 2, only two of 20 emotions showed consistency, and three colors showed specificity. As with the first study, no color-emotion pairings were both specific and consistent. In addition, in study 2, we found that saturation and lightness, and to a lesser extent hue, predicted color-emotion agreement rather than perceived color. The results suggest that previous studies which report emotion-color pairings are likely best thought of experiment-specific. The results are discussed with respect to constructionist theories of emotion.

Variable Significance of Brain MRI Findings in Infective Endocarditis and Its Effect on Surgical Decisions.

OBJECTIVE: To determine how brain magnetic resonance imaging (MRI) findings impact clinical outcomes in patients with infective endocarditis (IE) and to propose a management algorithm for patients with neurologic symptoms who are candidates for valve surgery (VS). PATIENTS AND METHODS: Data from our center were retrospectively reviewed for patients hospitalized with IE between January 1, 2007, and December 31, 2014. Outcomes were postoperative intracerebral hemorrhage (ICH), 6-month mortality, and functional outcome at last follow-up as described by the modified Rankin Scale (mRS) score. Good outcome was defined as an mRS score of 2 or less. RESULTS: A total of 361 patients with IE were identified, including 127 patients (35%) who had MRI. One hundred twenty-six of 361 patients (35%) had neurologic symptoms, which prompted MRI in 79 of 127 patients (62%); 74 of 79 (94%) had acute or subacute MRI abnormalities. One patient with subarachnoid and multifocal ICH on MRI developed postoperative ICH. Patients with VS despite MRI abnormalities had lower 6-month mortality (odds ratio [OR], 0.17; 95% CI, 0.06-0.48; P<.001) and better functional outcome (OR, 4.43; 95% CI, 1.51-13.00; P=.005). Irrespective of VS, lobar or posterior fossa ICH on MRI was associated with 6-month mortality (OR, 3.58; 95% CI, 1.22-10.50; P=.02) and territorial ischemic stroke was inversely associated with good mRS (OR, 0.29; 95% CI, 0.13-0.66; P=.002). In neurologically asymptomatic patients who had VS, MRI findings did not impact 6-month mortality or functional outcomes. CONCLUSION: Magnetic resonance imaging detects a large number of abnormalities in patients with IE. Preoperative lobar hematoma and large territorial stroke determine outcome irrespective of VS. When indicated, VS increases the odds of a good outcome despite MRI abnormalities.

Emotion Words' Effect on Visual Awareness and Attention of Emotional Faces.

To explore whether the meaning of a word changes visual processing of emotional faces (i.e., visual awareness and visual attention), we performed two complementary studies. In Experiment 1, we presented participants with emotion and control words and then tracked their visual awareness for two competing emotional faces using a binocular rivalry paradigm. Participants experienced the emotional face congruent with the emotion word for longer than a word-incongruent emotional face, as would be expected if the word was biasing awareness toward the (unseen) face. In Experiment 2, we similarly presented participants with emotion and control words prior to presenting emotional faces using a divided visual field paradigm. Emotion words were congruent with either the emotional face in the right or left visual field. After the presentation of faces, participants saw a dot in either the left or right visual field. Participants were slower to identify the location of the dot when it appeared in the same visual field as the emotional face congruent with the emotion word. The effect was limited to the left hemisphere (RVF), as would be expected for linguistic integration of the word with the face. Since the task was not linguistic, but rather a simple dot-probe task, participants were slower in their responses under these conditions because they likely had to disengage from the additional linguistic processing caused by the word-face integration. These findings indicate that emotion words bias visual awareness for congruent emotional faces, as well as shift attention toward congruent emotional faces.

Application of the FOUR Score in Intracerebral Hemorrhage Risk Analysis.

BACKGROUND: The Full Outline of Unresponsiveness (FOUR) Score is a validated scale describing the essentials of a coma examination, including motor response, eye opening and eye movements, brainstem reflexes, and respiratory pattern. We incorporated the FOUR Score into the existing ICH Score and evaluated its accuracy of risk assessment in spontaneous intracerebral hemorrhage (ICH). MATERIALS AND METHODS: Consecutive patients admitted to our institution from 2009 to 2012 with spontaneous ICH were reviewed. The ICH Score was calculated using patient age, hemorrhage location, hemorrhage volume, evidence of intraventricular extension, and Glasgow Coma Scale (GCS). The FOUR Score was then incorporated into the ICH Score as a substitute for the GCS (ICH ScoreFS). The ability of the 2 scores to predict mortality at 1 month was then compared. RESULTS: In total, 274 patients met the inclusion criteria. The median age was 73 years (interquartile range 60-82) and 138 (50.4%) were male. Overall mortality at 1 month was 28.8% (n = 79). The area under the receiver operating characteristic curve was .91 for the ICH Score and .89 for the ICH ScoreFS. For ICH Scores of 1, 2, 3, 4, and 5, 1-month mortality was 4.2%, 29.9%, 62.5%, 95.0%, and 100%. In the ICH ScoreFS model, mortality was 10.7%, 26.5%, 64.5%, 88.9%, and 100% for scores of 1, 2, 3, 4, and 5, respectively. CONCLUSIONS: The ICH Score and the ICH ScoreFS predict 1-month mortality with comparable accuracy. As the FOUR Score provides additional clinical information regarding patient status, it may be a reasonable substitute for the GCS into the ICH Score.

Ventriculostomy and Risk of Upward Herniation in Patients with Obstructive Hydrocephalus from Posterior Fossa Mass Lesions.

BACKGROUND: Patients with posterior fossa lesions causing obstructive hydrocephalus present a unique clinical challenge, as relief of hydrocephalus can improve symptoms, but the perceived risk of upward herniation must also be weighed against the risk of worsening or continued hydrocephalus and its consequences. The aim of our study was to evaluate for clinically relevant upward herniation following external ventricular drainage (EVD) in patients with obstructive hydrocephalus due to posterior fossa lesions. METHODS: We performed a retrospective review of patients undergoing urgent/emergent EVD placement at our institution between 2007 and 2014, evaluating the radiographic and clinical changes following treatment of obstructive hydrocephalus. RESULTS: Even prior to EVD placement, radiographic upward herniation was present in 22 of 25 (88%) patients. The average Glasgow Coma Scale of patients before and after EVD placement was 10 and 11, respectively. Radiographic worsening of upward herniation occurred in two patients, and upward herniation in general persisted in 21 patients. Clinical worsening occurred in two patients (8%), though in all others the clinical examination remained stable (44%) or improved (48%) following EVD placement. Of the patients who had a worsening clinical exam, other variables likely also contributed to their decline, and cerebrospinal fluid diversion was likely not the main factor that prompted the clinical change. CONCLUSIONS: Radiographic presence of upward herniation was often present prior to EVD placement. Clinically relevant upward herniation was rare, with only two patients worsening after the procedure, in the presence of other clinical confounders that likely contributed as well.

Medulla Oblongata Hemorrhage and Reverse Takotsubo Cardiomyopathy.

BACKGROUND: Acute brain injury with strong surges of adrenergic outflow has resulted in takotsubo cardiomyopathy, but there are surprisingly few reports of takotsubo cardiomyopathy after intracranial hemorrhage, and none have been described from hemorrhage within the brainstem. RESULTS: We describe a patient with reverse and reversible cardiomyopathy following a hemorrhage in the lateral medulla oblongata. While it is limited in size, the location of the hemorrhage caused acute systolic failure with left ventricular ejection fraction of 27% and vasopressor requirement for cardiogenic shock and pulmonary edema. There was full recovery after 7 days. METHODS: Detailed case report. CONCLUSION: Hemorrhage into medulla oblongata pressor centers may result in acute, reversible, stress-induced cardiomyopathy, affirming the adrenergic origin of this condition.

Variability of stroke patients meeting endovascular stroke trial criteria in a non-clinical trial setting.

BACKGROUND: Five randomized trials proving the efficacy and safety of mechanical embolectomy for ischemic stroke within 8hours used differing radiological methods to select patients. We aimed to evaluate the proportion of patients in clinical practice that would meet radiological criteria for inclusion in these trials. METHODS: Retrospective study of ischemic stroke patients at a large academic medical center who were considered for endovascular stroke therapy based on confirmed intracranial large vessel occlusion from April 2010-November 2014. All patients underwent computed tomography (CT) perfusion and CT angiogram. RESULTS: Of 119 patients, median age was 69 years (IQR 57-79) and median NIHSS 18 (IQR 14-21). Most patients had ASPECTS≥6 (n=105, 88.2%). All 119 patients met radiological criteria for MR CLEAN while 105 (88.2%) met criteria for SWIFT-PRIME, 96 (80.7%) for REVASCAT, 80/116 (69.0%) for EXTEND-IA, and 74 (62.2%) for ESCAPE. About half (n=58,48.7%) were treated with IV rtPA and 66 (56%) underwent endovascular therapy. Any intracranial hemorrhage was more common in patients undergoing endovascular therapy than in those who were not (36% vs. 17%, P=0.034). The frequency of symptomatic intracranial hemorrhage (ICH) did not significantly differ between these groups (6% vs. 4%, P=0.691). CONCLUSIONS: The proportion of patients with acute stroke and large vessel occlusion presenting within 8 hours that would meet radiological criteria for endovascular stroke trials varies considerably (62-100%) in a cohort outside of clinical trials from an academic comprehensive stroke center. Thus, the radiological criteria used for candidate selection in daily practice will greatly influence the proportion of patients treated with endovascular therapy.

Emotion words: Adding face value.

Despite a growing number of studies suggesting that emotion words affect perceptual judgments of emotional stimuli, little is known about how emotion words affect perceptual memory for emotional faces. In Experiments 1 and 2 we tested how emotion words (compared with control words) affected participants' abilities to select a target emotional face from among distractor faces. Participants were generally more likely to false alarm to distractor emotional faces when primed with an emotion word congruent with the face (compared with a control word). Moreover, participants showed both decreased sensitivity (d') to discriminate between target and distractor faces, as well as altered response biases (c; more likely to answer "yes") when primed with an emotion word (compared with a control word). In Experiment 3 we showed that emotion words had more of an effect on perceptual memory judgments when the structural information in the target face was limited, as well as when participants were only able to categorize the face with a partially congruent emotion word. The overall results are consistent with the idea that emotion words affect the encoding of emotional faces in perceptual memory. (PsycINFO Database Record

Anoxic-Ischemic Brain Injury.

Improvements in cardiopulmonary resuscitation and intensive care medicine have led to declining mortality rates for patients with out-of-hospital cardiac arrest, but overall it is still a minority that achieves good outcomes. Estimating neurologic prognosis for patients that remain comatose after resuscitation remains a challenge and the need for accurate and early prognostic predictors is crucial. A thoughtful approach is required and should take into account information acquired from multiple tests in association with neurologic examination. No decision should be made based on a single predictor. In addition to clinical examination, somatosensory evoked potentials, electroencephalogram, serum biomarkers, and neuroimaging provide complimentary information to inform prognosis.