Isolated oculomotor nerve palsy as a manifestation of diffuse large B cell lymphoma: A case report.

An isolated third nerve palsy presenting as the primary manifestation of a lymphoma is rare, with only few cases having been described. The present study reports an unusual case of a healthy 67-year old male diagnosed with isolated right oculomotor nerve palsy (ONP), who was found to have an underlying B cell lymphoma. The patient's medical records were accessed upon consent. A thorough physical examination, including stroke and infections work-ups were performed. A chest computerized tomography (CT), brain magnetic resonance imaging and positron emission tomography (PET) scans and a mediastinal tissue biopsy, were performed as part of systematic diagnostic evaluations. The current report suggests that a PET fluorodeoxyglucose study or a CT scan of the chest, abdomen and pelvis (with contrast) may help in the early diagnosis of a cancer responsible for ONP, particularly if brain vessel imaging does not show a posterior cerebral artery aneurysm as a cause for the defect.

Ventilator-associated pneumonia in critically ill stroke patients: frequency, risk factors, and outcomes.

PURPOSE: Our main objective was to assess incidence, risk factors, and outcomes of ventilator-associated pneumonia (VAP) in stroke patients. MATERIALS AND METHODS: After obtaining approval from the Human Studies Committee, we reviewed the electronic records from our intensive care unit database of 111 stroke patients on mechanical ventilation for more than 48 hours. Thirty-six risk factors related to disease and general health status, and 8 related to care-all assigned a priori-were collected and analyzed. Selected factors with univariate statistical significance (P < .05) were then analyzed with multivariate logistic regression. RESULTS: Thirty-one patients developed pneumonia (28%). Methicillin-resistant Staphylococcus aureus (n = 12) and methicillin-sensitive S aureus (n = 7) were the most common pathogenic bacteria. Chronic lung disease, neurological status at admission as assessed by the National Institutes of Health Stroke Scale, and hemorrhagic transformation were the independent risk factors contributing to VAP. Worsening oxygenation index (arterial partial pressure of oxygen/fraction of inspired oxygen) and proton pump inhibitor use for ulcer prophylaxis were other potentially important factors. CONCLUSIONS: Pneumonia appears as a frequent problem in mechanically ventilated stroke patients. Chronic lung disease history, severity of stroke level at admission, and hemorrhagic transformation of stroke set the stage for developing VAP. The duration of both mechanical ventilation and intensive care unit stay gets significantly prolonged by VAP, but it does not affect mortality.

Clinical usefulness of a biomarker-based diagnostic test for acute stroke: the Biomarker Rapid Assessment in Ischemic Injury (BRAIN) study.

BACKGROUND AND PURPOSE: One of the significant limitations in the evaluation and management of patients with suspected acute cerebral ischemia is the absence of a widely available, rapid, and sensitive diagnostic test. The objective of the current study was to assess whether a test using a panel of biomarkers might provide useful diagnostic information in the early evaluation of stroke by differentiating patients with cerebral ischemia from other causes of acute neurological deficit. METHODS: A total of 1146 patients presenting with neurological symptoms consistent with possible stroke were prospectively enrolled at 17 different sites. Timed blood samples were assayed for matrix metalloproteinase 9, brain natriuretic factor, d-dimer, and protein S100beta. A separate cohort of 343 patients was independently enrolled to validate the multiple biomarker model approach. RESULTS: A diagnostic tool incorporating the values of matrix metalloproteinase 9, brain natriuretic factor, d-dimer, and S-100beta into a composite score was sensitive for acute cerebral ischemia. The multivariate model demonstrated modest discriminative capabilities with an area under the receiver operating characteristic curve of 0.76 for hemorrhagic stroke and 0.69 for all stroke (likelihood test P<0.001). When the threshold for the logistic model was set at the first quartile, this resulted in a sensitivity of 86% for detecting all stroke and a sensitivity of 94% for detecting hemorrhagic stroke. Moreover, results were reproducible in a separate cohort tested on a point-of-care platform. CONCLUSIONS: These results suggest that a biomarker panel may add valuable and time-sensitive diagnostic information in the early evaluation of stroke. Such an approach is feasible on a point-of-care platform. The rapid identification of patients with suspected stroke would expand the availability of time-limited treatment strategies. Although the diagnostic accuracy of the current panel is clearly imperfect, this study demonstrates the feasibility of incorporating a biomarker based point-of-care algorithm with readily available clinical data to aid in the early evaluation and management of patients at high risk for cerebral ischemia.

Acute ischemic stroke and hypothyroidism.

BACKGROUND: In Kentucky, the incidence and mortality associated with stroke are among the highest in the United States. Treatment of modifiable risk factors can significantly prevent stroke. Identification of additional risk factors may further reduce stroke risk. Hypothyroidism is linked to altered lipid metabolism and is associated with hyperhomocysteinemia. In this study, we examined a possible association between acute ischemic stroke (AIS) and hypothyroidism. METHODS: Records were reviewed on all consecutive patients admitted to the University of Louisville Stroke Center with a diagnosis of AIS or transient ischemic attack (TIA). RESULT: Our data revealed that 12% of patients with AIS or TIA had hypothyroidism. A significant difference was found between the prevalence of hyperhomocysteinemia in patients with hypothyroidism (45.4%) compared with the prevalence of hyperhomocysteinemia in euthyroid patients (27.8%). CONCLUSION: Hypothyroidism is common in patients with AIS and TIA. Elevated homocysteine levels associated with hypothyroidism suggest that hypothyroidism may represent a modifiable stroke risk factor. Prospective studies are needed to verify this association.