Drip and ship and mothership models of mechanical thrombectomy result in similar outcomes in acute ischemic stroke of the anterior circulation.

BACKGROUND: Stroke therapy has been transformed in recent years due to the availability of thrombolysis and mechanical thrombectomy (MT). Whether transferring the patient directly to a comprehensive stroke center (CSC, mothership model) is better than taking them to a primary stroke center (PSC) and then to a CSC for MT (drip and ship) is unclear but has important implications. We compared the performance of both models in a district of the Basque country, Spain. METHODS: This is a retrospective analysis of prospectively collected data of all acute ischemic stroke patients consecutively admitted to the Neurology Department of two institutions and eligible for MT over a 36-month period with anterior circulation large vessel occlusion (LVO). One center applied the mothership model and the other the drip-and-ship. The two models were compared in terms of mortality and functional status assessed by modified Rankin (mRS) scale at 90 days. As a surrogate of the effectiveness of the two models, all times pertinent to stroke therapy were recorded. RESULTS: A total of 187 patients were evaluated subjected to MT with the drip-and-ship model and 188 with mothership, with a median NIHSS of 15. Prior to MT, 17% of the drip-and-ship patients received thrombolysis and 26% in the mothership. Neither mortality rate nor mRS showed statistically significant differences 90 days after stroke. The time lapse from stroke to MT was optimal in both models; albeit being 10 minutes longer in the drip-and-ship model, it had no impact on patients' outcomes. CONCLUSIONS: Drip-and-ship and mothership models can provide optimal and similar results in acute stroke patients in terms of mortality and functional status at 90 days. Their coexistence may alleviate the burden of CSC thus facilitating the access of more stroke patients to advanced therapies in an equitable manner.

Neurologic Manifestations in a Prospective Unselected Series of Hospitalized Patients With COVID-19.

BACKGROUND: An increasing number of neurologic problems are being described in coronavirus disease 2019 (COVID-19) disease, but their frequency and type have not been defined. In this study, we sought to determine the extent of neurologic manifestations of COVID-19 in a prospective series of unselected patients admitted to the general medicine wards of our hospitals due to COVID-19 and who were examined by a team of neurologists. METHODS: Eight neurologists provided medical attention to patients hospitalized for COVID-19 to provide medical support to other hospital units tasked with the care of an increasingly larger influx of patients with COVID-19. A series of 100 consecutive, unselected patients were evaluated systematically, including a questionnaire that collected medical information derived from the initial examination and the medical history. RESULTS: Eighty-eight percent of the patients had 1 neurologic manifestation associated with COVID-19 during hospitalization. Most common were anosmia-dysgeusia and headache (44% each), myalgias (43%), and dizziness (36%). Less frequent were encephalopathy (8%), syncope (7%), seizures (2%), and ischemic stroke during the period of hospitalization (2%). Anosmia and headache associated with younger patients with less severe disease, and both were associated with each other and with serum inflammatory markers. Encephalopathy was associated with fever and syncope and with markers of inflammation. CONCLUSIONS: Neurologic disturbances are common in patients with COVID-19, particularly if patients are evaluated by neurologists. There is a wide variety of neurologic conditions, some of them severe, in the spectrum of COVID-19 disease that will benefit from an evaluation by practicing neurologists.

Neurological reasons for consultation and hospitalization during the COVID-19 pandemic.

BACKGROUND: COVID-19 disease affects the nervous system and led to an increase in neurological consults for patients at admission and through the period of hospitalization during the peak of the pandemic. METHODS: Patients with clinical and laboratory diagnosis of COVID-19 that required a neurologic consultation or those who presented with neurological problems on admission that led to a diagnosis of SARS-CoV-2 infection during a 2-month period at the peak of the pandemic were included in this study. Demographic and clinical variables were analyzed. RESULTS: Thirty-five patients were included. The presenting neurologic manifestations on admission led to the diagnosis of COVID-19 in 14 patients (40%). The most common reasons for consultation during the hospitalization period were stroke (11), encephalopathy (7), seizures (6), and neuropathies (5) followed by a miscellaneous of syncope (2), migraine (1), anosmia (1), critical illness myopathy (1), and exacerbation of residual dysarthria (1). The most common neurological disturbances were associated with severe disease except for neuropathies. Patients with encephalopathies and seizures had markedly increased D-dimer and ferritin values, even higher than stroke patients. RT-PCR was performed in 8 CSF samples and was negative in all of them. CONCLUSION: Neurological disturbances represent a significant and severe burden in COVID-19 patients, and they can be the presenting condition that leads to the diagnosis of the viral infection in a high percentage of patients. Evidence of direct viral mechanisms was scarce, but the pathogenesis of the diverse manifestations remains enigmatic.

Predictors of in-hospital mortality after ischemic stroke: A prospective, single-center study.

BACKGROUND AND AIMS: Stroke is the second leading cause of death around the globe. Studies examining the predictors of in-hospital mortality and the impact of complications on early outcome of acute ischemic stroke are scant. The aim of this study was to identify predictors of in-hospital mortality in patients with acute ischemic stroke. METHODS: This was a prospective, single-center study of patients with acute ischemic stroke consecutively admitted to the Neurology Department of a general hospital during a 2-year period (from January 1, 2010 to December 31, 2011). Prospective data from this single-center study included variables related to sociodemographics, comorbidities, and medical complications, together with in-hospital mortality. Since stroke mortality may impact differently by sex and is also influenced by hospital length of stay, we proceeded to stratify by these variables. RESULTS: Six-hundred and seventy-three patients were included. Overall, in-hospital mortality rate was 7.13%. Stratifying by length of stay in-hospital (< 7 days and ≥ 7 days), we observed that within the first week, overall mortality was related to a history of previous stroke, higher stroke severity, and to cardiovascular and respiratory complications. After 7 days, the main factor independently associated with overall in-hospital mortality was stroke severity (National Institutes of Health Stroke Scale (NIHSS) ≥ 14, odds ratio (OR): 17.15; 95% CI, 3.06-96.07).Stratifying by sex, we observed that females had a worse outcome if there was a history of prior stroke (OR: 3.29; 95% CI, 1.19-9.10), higher stroke severity (NIHSS ≥ 14, OR: 16.63; 95% CI, 4.66-59.31), and cardiovascular complications (OR: 29.70; 95% CI, 5.70-154.8). Among men, stroke severity (NIHSS ≥ 14, OR: 23.19; 95% CI, 5.69-94.56), respiratory infections (OR: 3.84; 95% CI, 1.32-11.20), and older age had significant negative impact. CONCLUSIONS: Stroke severity and potentially modifiable complications (respiratory infections and cardiovascular complications) confer an increased risk of in-hospital death in both women and men, particularly during the first week of admission.

Unilateral or bilateral punctate hippocampal hyperintensities on DW-MRI: seizures, amnesia, or both?

The presence of small hippocampal hyperintense lesions on diffusion-weighted (DW) MRI can respond to different etiologies and represents a challenge where clinical judgment is imperative, since therapeutic approach may be quite different.We here report three patients with similar neuroradiological findings, i.e., hyperintense punctate hippocampal lesions on diffusion-weighted MRI sequences, yet of different origin. The first one presented with isolated amnesia (transient global amnesia), the second one with amnesia and seizures, and the third one with seizures.Thus, hippocampal punctate lesions appear after transient global amnesia, but the same pattern may be present after seizures, either focal-onset or generalized seizures. This peculiar radiological MRI pattern could indicate a pathogenic link between transient global amnesia (TGA) and seizures which should be further studied.

The goblet sign in the amnestic syndrome of the subcallosal artery infarct.

We here describe an acute-onset amnesic syndrome with evidence of an embolic infarction in the distribution of the subcallosal artery, a proximal branch of the anterior communicating artery. The infarction involved the corpus callosum genu and both fornices, giving a peculiar image on MRI that resembled a goblet. Although infrequent, the subcallosal artery infarction should be considered in the differential diagnosis of patients with an acute amnestic syndrome. We propose "the goblet sign" for the peculiar diffusion-weighted MRI image of the brain in this syndrome.

Alteraciones reversibles en los núcleos dentados y atrofia cerebral de rápida instauración debido a neurotoxicidad por litio / Reversible alterations in the dentate nuclei and rapid-onset cerebral atrophy due to neurotoxicity caused by lithium

Introducción. El tratamiento con litio puede ocasionar diversos efectos adversos neurológicos, incluso con niveles terapéuticos. Caso clínico. Mujer de 49 años, con trastorno bipolar y depresión, en tratamiento con litio, antidepresivos y antipsicóticos, que ingresó por un cuadro de alucinaciones visuales con una litemia elevada de 2,1 mEq/L (rango terapéutico: 0,6-1,2 mEq/L). Progresó a una encefalopatía grave que requirió asistencia respiratoria en la unidad de cuidados intensivos. La resonancia magnética cerebral inicial mostró una hiperintensidad simétrica bilateral reversible en los núcleos dentados en las secuencias T2 y T2-FLAIR. A lo largo de los meses posteriores desarrolló de forma progresiva un síndrome pancerebeloso con evidencia de una marcada pérdida de volumen bilateral en el cerebelo, sobre todo a expensas del vermis, que se acompañó clínicamente de un síndrome cerebeloso permanente e invalidante. Conclusiones. Aunque el tratamiento con litio ocasiona efectos adversos neurológicos variados, éstos suelen ser reversibles. Puede dar lugar a secuelas permanentes e incapacitantes, como la paciente descrita, con una atrofia cerebelosa marcada y progresiva, acompañada de secuelas permanentes en forma de síndrome cerebeloso invalidante. La neurotoxicidad cerebelosa del litio debe considerarse en el amplio diagnóstico diferencial que representa la ataxia cerebelosa del adulto (AU)

Introduction. Treatment with lithium can cause several neurological side effects, even at therapeutic levels. Case report. We report the case of a 49-year-old woman, with bipolar disorder and depression, undergoing treatment with lithium, antidepressants and antipsychotics, who was admitted to hospital due to a clinical picture of visual hallucinations with an elevated lithaemia of 2.1 mEq/L (therapeutic range: 0.6-1.2 mEq/L). The patient developed a severe encephalopathy that required the use of assisted ventilation in the intensive care unit. Initial magnetic resonance imaging showed a reversible bilateral symmetrical hyperintensity in the dentate nuclei in T2 and T2-FLAIR sequences. Over the following months she gradually developed a pancerebellar syndrome with evidence of a marked loss of bilateral volume in the cerebellum, above all at the expense of the vermis, which was accompanied by a permanent and disabling cerebellar syndrome. Conclusions. Although treatment with lithium can cause a variety of neurological side effects, they are usually reversible. However, they occasionally give rise to permanent and disabling sequelae, as in the case of the patient reported here, with a marked and progressive cerebellar atrophy, accompanied by permanent sequelae in the form of a disabling cerebellar syndrome. The cerebellar neurotoxicity of lithium must be taken into account in the broad differential diagnosis of cerebellar ataxia in adults (AU)

Influenza-associated seizures in healthy adults: Report of 3 cases.

To describe seizures occurring in 3 healthy adults with influenza infection. Seizures associated to influenza infection are rare in adults without encephalitis. Clinical observations of 3 healthy adult patients with influenza A and B infection and seizures. We present here 3 healthy adult patients with seizures related to influenza A or B infection without evidence encephalitis, encephalopathy or any other cause for seizures. Prognosis was excellent. Seizures can occur in healthy adults with influenza infection without evidence of encephalitis, a possibility to be borne in mind to avoid potentially harmful therapeutic and diagnostic procedures.

Automatic migraine classification via feature selection committee and machine learning techniques over imaging and questionnaire data.

BACKGROUND: Feature selection methods are commonly used to identify subsets of relevant features to facilitate the construction of models for classification, yet little is known about how feature selection methods perform in diffusion tensor images (DTIs). In this study, feature selection and machine learning classification methods were tested for the purpose of automating diagnosis of migraines using both DTIs and questionnaire answers related to emotion and cognition - factors that influence of pain perceptions. METHODS: We select 52 adult subjects for the study divided into three groups: control group (15), subjects with sporadic migraine (19) and subjects with chronic migraine and medication overuse (18). These subjects underwent magnetic resonance with diffusion tensor to see white matter pathway integrity of the regions of interest involved in pain and emotion. The tests also gather data about pathology. The DTI images and test results were then introduced into feature selection algorithms (Gradient Tree Boosting, L1-based, Random Forest and Univariate) to reduce features of the first dataset and classification algorithms (SVM (Support Vector Machine), Boosting (Adaboost) and Naive Bayes) to perform a classification of migraine group. Moreover we implement a committee method to improve the classification accuracy based on feature selection algorithms. RESULTS: When classifying the migraine group, the greatest improvements in accuracy were made using the proposed committee-based feature selection method. Using this approach, the accuracy of classification into three types improved from 67 to 93% when using the Naive Bayes classifier, from 90 to 95% with the support vector machine classifier, 93 to 94% in boosting. The features that were determined to be most useful for classification included are related with the pain, analgesics and left uncinate brain (connected with the pain and emotions). CONCLUSIONS: The proposed feature selection committee method improved the performance of migraine diagnosis classifiers compared to individual feature selection methods, producing a robust system that achieved over 90% accuracy in all classifiers. The results suggest that the proposed methods can be used to support specialists in the classification of migraines in patients undergoing magnetic resonance imaging.

Clinical Outcome of Mechanical Thrombectomy for Stroke in the Elderly.

BACKGROUND: Endovascular revascularization with mechanical devices has proven an effective treatment for proximal occlusions of the major intracranial arteries in stroke patients, but there is only limited information as to whether there should be an age limit for its use. We aimed to evaluate the safety and effectiveness of endovascular revascularization in stroke patients aged 80 years and older, and compare the results with younger patients. METHODS: We prospectively collected 81 consecutive patients subjected to mechanical thrombectomy for proximal occlusion of the anterior circulation during a period of 27 months. According to age, patients were divided into those aged less than 80 years (younger group) and those aged 80 years and older (elderly group). We analyzed favorable outcome, successful and futile recanalization, neurological improvement, in-hospital complications, and mortality in both groups. RESULTS: A favorable outcome (modified Rankin Scale score ≤2 at 3 months) was reached by 51.6% in the elderly group and 64% of younger patients, and neurological improvement (improvement of ≥4 points on National Institutes of Health Stroke Scale) was present in 77.4% of the elderly group. Overall, successful recanalization rates were 95.1% and futile recanalization reached 39% without statistically significant differences between both groups. Elderly patients presented more in-hospital complications (61.3% versus 38%) and higher mortality rates (16.1% versus 8%). CONCLUSIONS: Clinical independence was reached in over half of elderly stroke patients treated with mechanical thrombectomy, supporting the use of this treatment without age restriction.

Faciolingual Hemiparesis with Mild Limb Weakness of Cortical Origin.

The clinical combination of unilateral facial and hypoglossal palsy with upper limb weakness is known as the capsular genu syndrome and responds most often to an ischemic infarct in the internal capsule. We here describe a patient with this peculiar combination, in whom the responsible lesion was located in the contralateral prefrontal cortex, involving the corresponding areas of the Penfield's homunculus. Contralateral cortical frontal lesions should be considered in patients with facial and hypoglossal palsy with upper limb weakness.

Familial behavioral variant frontotemporal dementia associated with astrocyte-predominant tauopathy.

A familial behavioral variant frontotemporal dementia associated with astrocyte-predominant tauopathy is described in 2 sisters born from consanguineous parents. The neuropathologic examination revealed massive accumulation of abnormally hyperphosphorylated, conformational, truncated tau at aspartic acid 421, ubiquitinated and nitrated tau at Tyr29 in cortical astrocyte (including their perivascular foot processes), and Bergmann glia. Smaller amounts of abnormal tau were observed in neurons and rarely in oligodendrocytes. There was decreased expression of glial glutamate transporter in the majority of tau-positive astrocytes. Gel electrophoresis of sarkosyl-insoluble fractions showed 2 bands of 64 and 60 kDa and a doublet of 67 to 70 kDa (which are different from those seen in Alzheimer disease and in typical 4R and 3R tauopathies) together with several bands of lower molecular weight indicative of truncated tau. Analysis of the expression of MAPT isoforms further revealed altered splicing and representation of tau isoforms involving exons 2, 3, and 10. Genetic testing revealed no known mutations in PSEN1, PSEN2, APP, MAPT, GRN, FUS, and TARDBP and no pathologic expansion in C9ORF72. However, a novel rare heterozygous sequence variant(p.Q140H) of uncertain significance was identified in FUS in both siblings.

Low cognitive reserve is associated with chronic migraine with medication overuse and poor quality of life.

OBJECTIVE: The objective of this article is to test the hypothesis that cognitive reserve (CR) is related to migraine chronification, medication overuse and poor quality of life in migraineurs. DESIGN/METHODS: A cross-sectional study on patients with chronic migraine with medication overuse (CM-MOH), episodic migraine (EM), and controls, matched by sex, age and education, was carried out. CR was assessed by a specific questionnaire, and quality of life was measured by general and specific questionnaires (SF-36 and MSQoL). Migraine Disability Assessment Scale and Beck questionnaires for depression and anxiety were used. Medication dependence was evaluated by the medication-dependence questionnaire in headache (MDQ-H). RESULTS: Fifty-five individuals were enrolled: 18 CM-MOH patients (32.73%), 22 EM patients (40%) and 15 controls (27.27%). Fifty (90.91%) of them were females and aged 43.53 (7.54) years.Univariate analysis showed a significant association between the study group and CR, and all items of the SF-36, anxiety and depression questionnaires, MSQoL and MDQ-H. The lower CR and CM-MOH group were related to a worse quality of life, more anxiety and depression and the highest medication dependence scores.Multivariate analysis showed that higher CR scores were related to higher quality of life as measured by the physical and mental composite scores of the SF-36, and to lower anxiety (beta = -1.08, p = 0.001) and depression (beta = -0.56, p = 0.03) levels. Focusing on MSQoL, the increase in CR was predictive of a better quality of life (beta = 1.88, p < 0.0001). By all the models, the explained variance of the sample ranged from 39% (mental composite score) to 58% (MSQoL). CONCLUSIONS: Low CR appears to be an independent factor associated with the deterioration of quality of life, the presence of anxiety and depression, and drug dependence and medication overuse in CM-MOH.