Clinical Characteristics and Neuroimaging Correlations in Autoimmune Encephalitis: A Report of Two Cases.

Autoimmune encephalitis is an infrequent pathological occurrence documented within our local context. When clinical suspicion arises, employing electroencephalogram and brain magnetic resonance imaging (MRI) proves valuable. However, for conclusive diagnosis confirmation, lumbar puncture for cerebrospinal fluid (CSF) analysis is indispensable. Managing this condition involves a combination of immunosuppression and, when necessary, tumor resection. We document the initial cases reported in our city, featuring two young patients without significant pre-existing conditions. Patients initially displayed behavioral alterations progressing to altered consciousness, febrile peaks, and challenging epileptic status, requiring intensive care and mechanical ventilation. The diagnosis was made based on MRI and anti-N-methyl-D-aspartate (anti-NMDA) antibodies. Treatment involved intravenous (IV) immunoglobulins, plasmapheresis, and corticosteroids. After discharge, both had cognitive sequelae. Autoimmune encephalitis is a pathological condition that still lacks thorough exploration and reporting. It predominantly affects young patients without a history of acute psychiatric symptoms, necessitating consideration when behavioral alterations emerge. The challenges faced by small cities, including a shortage of technical resources, further impede the timely and precise diagnosis of this intricate condition.

Bilateral medial medullary stroke: "The heart sign".

Bilateral medial medullary stroke is a very rare condition. It is usually associated with severe motor deficits, dysarthria, sensory symptoms, nystagmus, and respiratory disturbances. The most common etiology is atherosclerotic disease of the vertebral and anterior spinal artery or its branches. We present the case and brain imaging of a 48-year-old man with a bilateral medial medullary stroke and its classic "Heart Sign" in the magnetic resonance imaging. This case highlights the anatomy of the rostral medulla, clinical presentation, etiology, and characteristic radiologic findings of this uncommon type of stroke.

Utility of Repetitive Transcranial Magnetic Stimulation for Chronic Daily Headache Prophylaxis: A Systematic Review and Meta-Analysis.

PURPOSE OF REVIEW: Management of chronic daily headaches (CDH) remains challenging due to the limited efficacy of standard prophylactic pharmacological measures. Several studies have reported that repetitive transcranial magnetic stimulation (rTMS) can effectively treat chronic headaches. The objective was to determine the utility of rTMS for immediate post-treatment and sustained CDH prophylaxis. RECENT FINDINGS: All procedures were conducted per PRISMA guidelines. PubMed, Scopus, Web of Science, and ProQuest databases were searched for controlled clinical trials that have tested the efficacy of rTMS on populations with CDH. DerSimonian-Laird random-effects meta-analyses were performed using the 'meta' package in R to examine the post- vs. pre-rTMS changes in standardized headache intensity and frequency compared to sham-control conditions. Thirteen trials were included with a combined study population of N = 538 patients with CDH (rTMS, N = 284; Sham, N = 254). Patients exposed to rTMS had significantly reduced standardized CDH intensity and frequency in the immediate post-treatment period (Hedges' g = -1.16 [-1.89, -0.43], p = 0.002 and Δ = -5.07 [-10.05, -0.11], p = 0.045 respectively). However, these effects were sustained marginally in the follow-up period (Hedges' g = -0.43 [-0.76, -0.09], p = 0.012 and Δ = -3.33 [-5.52, -1.14], p = 0.003). Significant between-study heterogeneity was observed, at least partially driven by variations in rTMS protocols. Despite the observed clinically meaningful and statistically significant benefits in the immediate post-treatment period, the prophylactic effects of rTMS on CDH do not seem to sustain with discontinuation. Thus, the cost-effectiveness of the routine use of rTMS for CDH prophylaxis remains questionable. REGISTRATION: Protocol preregistered in PROSPERO International Prospective Register of Systematic Reviews (CRD42021250100).

Mechanical Venous Thrombectomy Using Indigo Aspiration System: A Case Report.

We present a case of successful endovascular thrombectomy of cerebral venous sinus thrombosis utilizing Penumbra's Indigo Aspiration System (Penumbra Inc., Place Alameda, CA), a minimally invasive system with a large-lumen (Indigo System CAT7, 7F) catheter predominantly used for the removal of thromboembolism involving the peripheral arterial and venous systems. A 30-year-old female presented with a seizure and focal neurological deficits and was found to have a left posterior temporal lobe hemorrhagic infarct secondary to an extensive cerebral venous sinus thrombosis extending from the left transverse sinus to the ipsilateral internal jugular bulb. We considered the combination of seizure, motor deficit, and hemorrhagic infarct high-risk features for poor response to standard medical therapy with therapeutic anticoagulation. Therefore, we performed a mechanical venous thrombectomy with the above device in addition to anticoagulation treatment with heparin infusion. This combination therapy resulted in a technically successful radiographic recanalization of the involved sinuses and an excellent functional outcome at follow-up. This case demonstrates that this trackable, atraumatic, large-bore system was safe and efficacious in the cerebral venous system, permitting near-complete thrombus removal.

Predicting poor response to anti-coagulation therapy in cerebral venous thrombosis using a simple clinical-radiological score.

BACKGROUND: Multiple studies have attempted to determine predictors of poor clinical outcomes in cerebral venous thrombosis (CVT). Fewer studies target to identify predictors of poor response to anticoagulation therapy in CVT. OBJECTIVE: We aimed to determine the predictors of poor clinical response to therapeutic anticoagulation in patients with acute CVT. METHODS: We performed a retrospective analysis of patients therapeutically anticoagulated for acute CVT. We defined poor clinical outcomes as death, need for mechanical thrombectomy during the hospitalization, or a modified Rankin Scale (mRS) > 3 at clinical follow-up. Bivariate and multivariate analyses identified factors associated with poor outcomes in anticoagulated patients for acute CVT, and we used the identified factors to create the PRACT-CVT (Poor Response to Anticoagulation Therapy in CVT) score. RESULTS: We included 109 patients anticoagulated with acute CVT. The mean patient age was 37 years old (SD 19); nine patients were > 65 years, ten patients were < 10 years, and 64 (59%) were female. Twenty-one (19%) patients had poor clinical outcomes. Age > 65 or < 10 years (OR: 3.16, 95% CI: 1.06-9.44), a GCS ≤ 12 upon presentation (OR: 19.2, 95% CI: 4.05-91.4), focal motor deficits at admission (OR: 5.03, 95% CI: 1.64-15.44), clinical deterioration following admission (OR: 28.18, CI: 4.81-164.86), seizures following admission (OR: 5.59, 95% CI: 1.27-24.51), evidence of brain bleeding/ischemia on admission (OR: 4.67, 95% CI: 1.42-15.34), involvement of the superior sagittal sinus (OR: 3.88, CI: 1.33-11.32), or involvement of both transverse sinuses (OR: 3.87, 95% CI: 1.01-14.90) predicted poor clinical outcome despite therapeutic anticoagulation. A PRACT-CVT score (0-22 points) of ≥ 7 points provided a sensitivity of 71% and a specificity of 95% for predicting poor clinical outcomes with anticoagulation alone. CONCLUSION: Patients with acute CVT aged > 65 or < 10 years old, presenting with a GCS ≤ 12, with focal motor deficits, showing clinical deterioration after admission, having clinical seizures during hospitalization, with brain bleeding/ischemia on initial neuroimaging, involvement of the superior sagittal sinus, or involvement of both transverse sinuses had poor response to anticoagulation. Clinicians may employ the PRACT-CVT score to predict poor response to anticoagulation for acute CVT.

Demographic and institutional predictors of stroke hospitalization mortality among adults in the United States.

INTRODUCTION: Stroke remains a primary source of functional disability and inpatient mortality in the United States (US). Recent evidence reveals declining mortality associated with stroke hospitalizations in the US. However, data updating trends in inpatient mortality is lacking. This study aims to provide a renewed inpatient stroke mortality rate in a national sample and identify common predictors of inpatient stroke mortality. METHODS: In this cross-sectional study, we analyzed data from a nationwide database between 2010 and 2017. We included patient encounters for both ischemic (ICD9 433-434, ICD10 I630-I639) and hemorrhagic stroke (ICD9 430-432, ICD10 I600-I629). We performed an annual comparison of in-hospital stroke mortality rates, and a cross-sectional analytic approach of multiple variables identified common predictors of inpatient stroke mortality. RESULTS: Between 2010 and 2017, we identified 518,185 total stroke admissions (86.6% ischemic stroke and 13.4% hemorrhagic strokes). Stroke admissions steadily increased during the studied period, whereas we observed a steady decline in in-hospital mortality during the same time. The inpatient stroke mortality rate gradually declined from 4.8% in 2010 (95% CI 4.6-5.1) to 2.1% in 2017 (95% CI 2.0-2.1). Predictors of higher odds of dying from ischemic stroke were female (OR 1.059, 95% CI 1.015-1.105, p = 0.008), older age (OR 1.028, 95% CI 1.026-1.029, p < 0.001), and sicker patients (OR 1.091, 95% CI 1.089-1.093, p < 0.001). Predictors of higher odds of dying from hemorrhagic stroke were Hispanic ethnicity (OR 1.459, 95% CI 1.084-1.926, p < 0.001), older age (OR 1.021, 95% CI 1.019-1.023, p < 0.001), and sicker patients (OR 1.042, 95% CI 1.039-1.045, p < 0.001). All census regions and hospital types demonstrated improvements in in-hospital mortality. CONCLUSION: This study identified a continuous declining rate in in-hospital mortality due to stroke in the United States, and it also identified demographic and hospital predictors of inpatient stroke mortality.

Intravenous thrombolysis for the management of acute ischemic stroke in patients therapeutically anticoagulated with heparin: A review.

BACKGROUND: Intravenous thrombolysis (IVT) with alteplase is effective in acute ischemic stroke (AIS). However, its use rate remains low due to the many exclusion criteria. Recent guidelines recommend excluding patients suffering AIS with an elevated aPTT secondary to heparin exposure from receiving IVT. The purpose of this review is to explore the safety and efficacy of IVT in patients therapeutically anticoagulated with heparin. We also propose a treatment algorithm for IVT in patients with AIS that are therapeutically anticoagulated with heparin. METHODS: We performed a systematic review of PubMed and Embase through March 2020 to identify the literature regarding AIS in patients exposed to heparin, followed by IVT treatment, emphasizing safety, efficacy, and clinical outcome using PRISMA guidelines. RESULTS: We included thirteen articles in the final analysis, including three retrospective studies, two observational studies, one randomized trial, five case reports, and two case series. CONCLUSION: There is limited information about the off-label use of IVT in patients with elevated aPTT. Patients with AIS are excluded from IVT if they have recent exposure to heparin. Our review indicates that this population of patients may benefit from IVT as the cases of active bleeding after IVT are few, and functional outcomes are favorable in the long term suggesting that IVT in therapeutically anticoagulated patients may be safe and efficacious.

Self-inflicted transorbital pontine stab injury with a retained pen.

Self-inflicted transorbital stab injuries are not commonly seen in clinical practice. These lesions usually lead to major disability depending on the intracranial structures transected. We present a case of a 34-year-old man with a self-inflicted stab injury in his right orbit from a pen. Computed tomography revealed that the pen crossed intracranially from the orbit to the posterior fossa and pierced the pons. Such injuries are usually seen in the context of major psychiatric or drug abuse disorders. A multidisciplinary approach between ophthalmology and neurosurgery is essential in the management of these patients.

Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Esclerosis Múltiple en Adultos / Clinical Practice Guidelines: Diagnostic and Treatment of Multiple Sclerosis in Adults

La Esclerosis Múltiple (EM) es una enfermedad crónica del sistema nervioso central, para la cual aún no hay una cura definitiva; sin embargo, existe una diversa variedad de terapias con el objetivo de modificar el curso natural de la enfermedad, que promueve la inclusión constante de nuevas estrategias terapéuticas. Objetivo: La Sociedad Peruana de Neurología, por encargo del Ministerio de Salud, convocó a un comité de expertos con el objetivo de elaborar una guía de práctica clínica para el diagnóstico y tratamiento de EM. Método: Se realizó una búsqueda y evaluación de guías de práctica clínica bajo la metodología AGREE II, escogiendo como modelo la Guía de Práctica Clínica Catalana. Las preguntas clínicas no concernientes al tratamiento fueron resueltas a través de revisión sistemática. Las preguntas clínicas de tratamiento se diseñaron bajo el formato PICO y se resolvieron con un meta-análisis de ensayos clínicos disponibles hasta agosto del 2017, tomando en consideración las terapias aprobadas por DIGEMID hasta enero del 2017. Las recomendaciones finales fueron elaboradas mediante el método Delphi modificado con un consenso de al menos 80% de los miembros de su comité. Finalmente se realizó una revisión externa del manuscrito por expertos internacionales en EM. Resultados: Se formularon 18 preguntas clínicas y 21 recomendaciones para el manejo, incluyendo algoritmos terapéuticos.

Multiple Sclerosis (MS) is a chronic disease of the central nervous system, for which there is still no definitive cure; but there is a diverse variety of therapies with the objective of modifying the course of the disease, which promotes the constant inclusion of new therapeutic strategies. Objective: The Peruvian Society of Neurology, as requested by the Peruvian Health Ministry, convened a committee of experts with the purpose of elaborating a clinical practice guideline for the diagnosis and treatment of MS. Method: Clinical practice guidelines were searched and evaluated according to the AGREE II methodology, choosing the Catalan Clinical Practice Guide as a model. The clinical questions not related to treatment were solved through a systematic review. The clinical treatment questions were assessed under the PICO format and were solved with a meta-analysis of clinical trials available until August 2017, considering the therapies approved by DIGEMID until January 2017. The final recommendations were elaborated using the modified Delphi method with a consensus of at least 80% of the members of its committee. Finally, an external revision of the manuscript was made by international experts in MS. Results: Eighteen clinical questions and twenty-one recommendations for management were developed, including therapeutic algorithms.

Atención en el consultorio de ginecoobstetricia de la adolescente / Attention in the office of the teenager gynecoobstetrics

Objetivo: Determinar las características de la atención del Consultorio de Ginecoobstetricia de la Adolescente. Diseño: Estudio observacional, retrospectivo, longitudinal y descriptivo. Lugar: Departamento de Obstetricia y Ginecología del Hospital Nacional Cayetano Heredia (HNCH). Material y Métodos: Revisión de las hojas de atención HIS del Consultorio de Ginecoobstetricia de la Adolescente de los años 1998 y 1999. Resultados: Se encontró 3304 pacientes: 7,3 por ciento era adolescente temprana, 30,2 por ciento adolescente media y 62,5 por ciento adolescente tardía. La patología ginecológica representó el 88,4 por ciento de los diagnósticos de las adolescentes tempranas, el 50,0 por ciento de las adolescentes medias y el 24,2 de las adolescentes tardías. La consulta obstétrica fue el 7,0 por ciento, 48,4 por ciento y 75,9 por ciento de las adolescentes tempranas, medias y tardías, respectivamente. Conclusiones: La patología ginecológica es el principal motivo de consulta en las adolescentes tempranas y medias y la consulta obstétrica lo es en las adolescentes tardías.

Objective: To determine attention characteristics at the Adolescent Gynecology and Obstetrics Outpatient Office. Design: Observational, retrospective, longitudinal and descriptive study. Setting: Department of Obstetrics and gynecology, Cayetano Heredia National Hospital. Materials and Methods: Review of HIS 1998 and 1999 attention files of the Adolescent Gynecology and Obstetrics Outpatient Office. Results: In 3304 patients, 7,3 per cent belonged to early adolescence, 30,2 per cent to middle adolescence and 62,5 per cent to late adolescence. Gynecologic pathology represented 88,4 per cent of all diagnosis in early adolescents, 50,0 per cent of middle adolescents and 24,2 of late adolescents. Obstetrical consultation was 7,0 per cent, 48,4 per cent and 75,9 per cent of early, middle and late adolescents, respectively. Conclusions: Gynecologic pathology was the main reason of consultation in early and middle adolescents and obstetrical consultation in late adolescents.