Population-based approaches for reducing stroke risk: an update on their success and the challenges ahead.

INTRODUCTION: Stroke is a significant public health challenge as it is the second most common cause of death and the third leading cause of disability globally. Additionally, stroke incidence and the number of stroke deaths have been rising. Efforts to prevent stroke have been made, including high-risk approaches where patients are screened for cardiovascular risk factors, and population-based approaches which attempt to reduce stroke rates by improving overall population health. AREAS COVERED: We summarize studies of population-based approaches to stroke prevention involving greater than 1,000 participants identified on a PubMed database search. Based on these programs, challenges of population-based stroke prevention programs are discussed and potential keys to success are highlighted. EXPERT OPINION: Population-based stroke prevention programs face challenges including cost and interest of the public and certain stakeholders. Additionally, secular trends for improvement in risk factors and catastrophic adverse environmental circumstances add to the complexity of analyzing program success. Factors leading to successful programs include validated digital solutions for self-monitoring of risks, backing by global policy and legislation, flexibility to the needs of the population, intersectoral programs, community engagement, information dissemination back to the populations, and high-risk screening to develop a complementary combination approach to stroke prevention.

CT Perfusion Imaging Guides Clinical Decision-Making in a Case of Thalamic Stroke: A Case Report.

This case highlights a patient presenting with a stroke code in the emergency department with decreased consciousness. The patient was later found to have bilateral thalamic strokes due to ischemia of the artery of Percheron. Initial head computed tomography (CT) and CT angiogram (CTA) of the head and neck showed no abnormalities. CT perfusion (CTP) showed a perfusion deficit of 169 mL with a T-max greater than 4 s and 4 mL with a T-max greater than 6 s in the posterior circulation. The patient received IV alteplase. This case report emphasizes the importance of perfusion neuroimaging in the evaluation of acute ischemic stroke.

Genotype-guided dual antiplatelet therapy in cerebrovascular disease: assessing the risk and benefits for ethnic populations.

INTRODUCTION: Cerebrovascular disease is a leading cause of morbidity and mortality in the world and antiplatelet therapy is a main pharmacologic means of secondary prevention. Clinical information has accumulated about benefit of dual antiplatelet therapy in certain clinical scenarios, genetic causes of antiplatelet resistance and its effect on clinical outcomes, and ethnic and geographic distributions of genetic polymorphisms. AREAS COVERED: This review covers literature related to the pharmacogenomics of antiplatelet agents with a focus on ethnic variability, antiplatelet resistance, and dual antiplatelet therapy in cerebrovascular disease. EXPERT OPINION: Selecting patients for dual antiplatelet therapy and specific agents require consideration of multiple factors. Ethnic factors should be considered in certain circumstances, but additional research is needed to determine the generalizability of the findings.

Malpractice Lawsuits Relating to Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review.

Background and Purpose: Medical-legal claims for malpractice relating to the use of alteplase for acute ischemic stroke (AIS) are usually for failure to treat rather than for complications. The advent of mechanical thrombectomy (MT) as a standard of AIS treatment has added a new dimension to the medical-legal landscape as there is a need for the delivery of a higher level of care creating the potential for delays and errors associated with such treatment. Information on causes of malpractice related to mechanical thrombectomy (MT) is currently lacking. Methods: We conducted a systematic review of legal databases (Westlaw, LexisNexis, Google Scholar Case Law, and VerdictSearch) to identify medical malpractice cases with and without verdicts filed in the United States up to March 31, 2021 which pertained to performance or non-performance of MT for AIS. We collected various case characteristics, case outcomes, and root causes for malpractice claims. Results: We found 25 cases, 16 of which alleged failure to treat with MT, 8 for harm due to delay in treatment and 1 case that alleged complications. Root causes included delay in vascular imaging, communication breakdowns, and transportation delays. Eight cases had an outcome in favor of the defendant, 9 in favor of the plaintiff, and 8 remained to be determined. Conclusions: As with alteplase, malpractice allegations regarding MT for AIS are largely for failure to treat or delay in treatment as opposed to complications. Addressing root causes of diagnostic delay, communication breakdowns, and transportation delays may reduce subsequent malpractice risk.

Anti-Hu-Associated Encephalomyelitis as a Presentation of Primary Extrapulmonary Small Cell Carcinoma of the Small Bowel: A Case Report.

Small cell carcinoma (SCC) is a neuroendocrine tumor (NET) commonly found in the lung, known for rapid proliferation and early metastasis. Extrapulmonary small cell carcinomas (ESCC) are rare, with GI tract carcinomas exceedingly so. Due to the lack of clinical data on the treatment of ESCC, the standard regimen is the same as the SCC of the lung. Documented accounts of paraneoplastic encephalomyelitis associated with NETs are also uncommon. We present a patient who suffered from neurologic deficits before being diagnosed with paraneoplastic encephalomyelitis from a duodenal ESCC. The patient presented with ear pain and hematemesis. New symptoms arose after the resolution of initial symptoms, including shortness of breath and numbness. Autoimmune workup was positive for anti-Hu antibodies. A position emission tomography (PET) scan showed increased uptake in the duodenal region. Biopsy results from a duodenal ulcer revealed poorly differentiated neuroendocrine carcinoma with positive synaptophysin and strong positivity of Ki-67, consistent with ESCC. Numerous treatments, including platinum-based chemotherapy, yielded no neurologic improvement for the patient. This case details an atypical presentation of ESCC, which should be considered in patients suspected of paraneoplastic encephalomyelitis.

Subarachnoid Hemorrhage due to Cerebral Cavernous Malformation in a Young Female.

Cerebral cavernous malformations (CCMs) are usually intraparenchymal lesions commonly associated with intraparenchymal hemorrhage. Extra-axial Lesions are uncommon and have rarely been reported as the cause of aneurysmal like subarachnoid hemorrhage (SAH). We present a 33-years-old female with a past medical history significant for hypertension who presented with acute onset head and neck pain after bending over. En route to the hospital, she had abnormal motor movements suggestive of seizures. Computed tomography (CT) of the head was significant for diffuse aneurysmal like SAH. Head CT angiography (CTA) and catheter digital subtraction angiography (DSA) were both negative for aneurysm. Magnetic resonance imaging (MRI) of the brain showed susceptibility artifact in the right parafalcine frontal lobe suspicious for underlying CCM. This lesion was in the area suspected of having an aneurysm on CT head. The patient was diagnosed with SAH secondary to cavernous malformation mimicking aneurysmal etiology. This case is important as it serves as a good reminder to consider cavernous malformations in the differential in patients presenting with angiogram negative SAH. Diagnosis of this entity has treatment implications including discontinuation of calcium channel blockers if initiated, discussion about duration of anti-seizure medication, in addition to consideration for surgical intervention in select populations.

Intracranial Hypertension in a Transgender Man.

Objective: Case description of recurrent idiopathic intracranial hypertension (IIH) in a transgender man on gender-affirming hormone therapy. Methods: Case report. Results: A 24-year-old transmasculine patient (assigned female at birth), with a body mass index (BMI) of 37.3, presented with headaches, transient visual obscurations (TVOs), pulsatile tinnitus, Frisén 5 papilledema, and scotomas. He was diagnosed with IIH after normal magnetic resonance imaging (MRI) and magnetic resonance venogram (MRV), an elevated opening pressure of 27 cm water, and normal cerebrospinal fluid studies. IIH resolved with acetazolamide and optic nerve sheath fenestration (ONSF). He then started gender-affirming testosterone therapy and was on this for 20 months when his headaches, pulsatile tinnitus, TVOs, and Frisén 3 papilledema recurred at a BMI of 31. Brain MRI and MRV were normal. Opening pressure was elevated at 31 cm. water. Acetazolamide 4 g/day did not improve the papilledema, thus a left ONSF was repeated resulting in eventual resolution of the IIH. Discussion: Several reports have been published of IIH development in patients receiving testosterone therapy. Hormone prescribers for gender affirmation may wish to screen for visual loss and optic nerve edema in patients undergoing testosterone therapy, which may also stimulate appetite weight gain.

Bilateral Non-Arteritic Anterior Ischaemic Optic Neuropathy in a Patient with a COL4A2 Mutation.

Non-arteritic anterior ischaemic optic neuropathy (NAION) is a common cause of vision loss in adults and is thought to be due to compromised perfusion to the optic nerve head. Patients with NAION in one eye are at risk of recurrence in the fellow eye. We report a case of sequential, bilateral NAION in a patient who was found to have a COL4A2 mutation. COL4A2 encodes a subunit of the collagen 4 protein, the major component of the human basement membranes, and has several known cerebrovascular and ocular associations.

The effects of lisdexamfetamine dimesylate on eating behaviour and homeostatic, reward and cognitive processes in women with binge-eating symptoms: an experimental medicine study.

Lisdexamfetamine dimesylate (LDX) is the only drug currently approved by the FDA for the treatment of Binge-Eating Disorder (BED), but little is known about the behavioural mechanisms that underpin the efficacy of LDX in treating BED. We examined the behavioural and neural effects of an acute dose of LDX (50 mg) in 22 women with binge-eating symptomatology using a randomised, crossover, double-blind, placebo-controlled experimental medicine design. LDX reduced self-reported appetite ratings and intake of both a pasta meal and a palatable cookie snack. LDX also decreased the eating rate of pasta but not of cookies and reduced self-reported liking ratings for pasta at the end of the meal. When viewing food pictures during an fMRI scan, LDX reduced activity bilaterally in the thalamus. LDX enhanced sustained attention and reduced impulsive responding in a continuous performance task but had no effect on emotional bias or working memory. These results suggest the observed effects of LDX on food intake (and by implication the efficacy of LDX in treating BED) may be related to the actions of the drug to enhance satiety, reduce food-related reward responding when full and/or increase cognitive control. Novel pharmacotherapies for BED might be most effective if they have a broad spectrum of effects on appetite, reward and cognition.

Late Diagnosis of Narcolepsy With Cataplexy: A Novel Case of Cataplectic Facies Presenting in an Elderly Woman.

None: Cataplectic facies is an unusual feature described in children with narcolepsy and cataplexy. The typical manifestations of cataplectic facies consist of repetitive mouth opening, tongue protrusion, and ptosis. An interesting observation is that the usual emotional triggers associated with cataplexy such as laughter and joking are not always present, thus hampering diagnosis of the underlying syndrome. Cataplectic facies is thought to be a phenomenon observed in the early stages of narcolepsy type 1 and is thought to disappear by the time the patient reaches puberty. We present a unique case of an elderly woman with narcolepsy type 1 demonstrating cataplectic facies. The novel circumstances of this case highlight that facial cataplexy can present later in life, in contrast with previous descriptions that report resolution of cataplectic facies before puberty. Wider recognition of these features throughout the life course may aid in accurate diagnosis and thereby ensure swift access to appropriate treatment.

Post-traumatic stress disorder in UK civilians with traumatic brain injury: an observational study of TBI clinic attendees to estimate PTSD prevalence and its relationship with radiological markers of brain injury severity.

OBJECTIVES: To estimate the prevalence of post-traumatic stress disorder (PTSD) in a large civilian population with traumatic brain injury (TBI), and to assess whether brain injury severity is correlated with PTSD symptoms. DESIGN: Observational, cross-sectional study. SETTING AND PARTICIPANTS: Outpatient clinic in a major UK trauma centre and secondary care hospital. Estimates of PTSD prevalence are based on 171 sampled individuals attending TBI clinic within an 18-month period. Analysis of the relationship between TBI severity and PTSD was performed on the subset of 127 patients for whom injury severity data were also available. METHODS: Civilian TBI clinic attendees completed validated self-report questionnaires assessing PTSD (PTSD Checklist Civilian Version (PCL-C)) and other psychiatric symptoms. From this, the prevalence of PTSD was estimated in our cohort. Postresuscitation Glasgow Coma Score and Marshall grade on CT brain scan were recorded as indicators of brain injury severity. A hierarchical regression explored whether TBI severity may predict PTSD scores. RESULTS: A high prevalence of PTSD was estimated (21% with PCL-C score >50). Higher Marshall grading displayed a slight negative correlation with PTSD symptoms. This statistically significant relationship persisted after confounding factors such as depression and postconcussion symptoms were controlled for. CONCLUSIONS: PTSD and TBI frequently coexist, share antecedents and overlap in their resultant symptoms. This complexity has given rise to conflicting hypotheses about relationships between the two. This research reveals that PTSD is common in civilians with TBI (adding to evidence drawn from military populations). The analysis indicated that more severe brain injury may exert a slight protective influence against the development of PTSD-potentially by disrupting implicit access to traumatic memories, or via overlapping neuropsychiatric symptoms that impede diagnosis. The association suggests that further research is warranted to explore the reuse of routine clinical and neuroimaging data-investigating its potential to predict risk of psychiatric morbidity.

Post-traumatic stress disorder and self-reported outcomes after traumatic brain injury in victims of assault.

INTRODUCTION: Assault is the third most common cause of traumatic brain injury (TBI), after falls and road traffic collisions. TBI can lead to multiple long-term physical, cognitive and emotional sequelae, including post-traumatic stress disorder (PTSD). Intentional violence may further compound the psychological trauma of the event, in a way that conventional outcome measures, like the Glasgow Outcome Scale (GOS), fail to capture. This study aims to examine the influence of assault on self-reported outcomes, including quality of life and symptoms of PTSD. METHODS: Questionnaire were completed by 256 patients attending a TBI clinic, including Quality of Life after Brain Injury (QOLIBRI) and PTSD checklist (PCL-C). Medical records provided demographics, clinical data and aetiology of injury. Subjective outcomes were compared between assault and other causes. RESULTS: Of 202 patients analysed, 21% sustained TBI from assault. There was no difference in severity of injuries between assault and non-assault groups. No relationship was found between self-reported outcomes and TBI severity or GOS. The assault group scored worse in all self-reported questionnaires, with statistically significant differences for measures of PTSD and post-concussion symptoms. However, using threshold scores, the prevalence of PTSD in assaulted patients was not higher than non-assault. After adjusting for age, ethnicity and the presence of extra-cranial trauma, assault did not have a significant effect on questionnaire scores. Exploratory analysis showed that assault and road traffic accidents were associated with significantly worse outcomes compared to falls. CONCLUSION: Quality of life is significantly related to functional and psychological outcomes after TBI. Assaulted patients suffer from worse self-reported outcomes than other patients, but these differences were insignificant when adjusted for demographic factors. Intentionality behind the traumatic event is likely more important than cause alone. Differences in quality of life and other self-reported outcomes are not reflected by the Glasgow Outcome Scale. This information is useful in arranging earlier and targeted review and support.

Minor head injury in children: evaluating written discharge advice provided by Scottish emergency departments.

OBJECTIVES: Emergency departments (EDs) routinely provide written information when a child with head injury (HI) is discharged home. This usually contains advice about recognizing signs of serious complications such as intracranial bleeding. This study evaluated the quality of discharge leaflets currently provided by Scottish emergency departments (EDs) by comparing them against written discharge advice recommended by the Scottish Intercollegiate Guideline Network (SIGN). METHODS: All 35 EDs in Scotland which treat children were asked to send a copy of the advice leaflet provided when a child with HI is discharged. Leaflets were evaluated by awarding scores for the inclusion of specific aspects of health information as recommended by SIGN. The inclusion of serious warning symptoms (maximum 20 points) and other advice on observation and help-seeking (maximum 21 points) was assessed. RESULTS: 34 EDs provided leaflets. The median score for including serious warning symptoms was 10/20. The median score for including advice regarding observation and when to seek help was 6.5/21. Several leaflets contained unclear or contradictory advice. CONCLUSION: Many leaflets did not include important information recommended by SIGN guidelines. There was considerable variation in the quality and clarity of written discharge advice provided. This may reduce the ability of parents to recognize rare but serious complications. It is recommended that a standardized HI information leaflet based on SIGN guidelines be used across all Scottish EDs.