Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke.

BACKGROUND AND PURPOSE: Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke. MATERIALS AND METHODS: Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively. RESULTS: Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes. CONCLUSIONS: Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals.

Brain attack: needing resuscitation.

The brain is extremely susceptible to focal ischaemia. Following vascular occlusion, a core of severely damaged brain tissue develops, surrounded by an ischaemic penumbra. This potentially-salvageable penumbra may be estimated by advanced neuroimaging techniques, particularly by diffusion-perfusion mismatch. Clinical trials have demonstrated the efficacy of intravenous thrombolysis within three hours of onset of ischaemic stroke in reducing short-term disability. Recanalisation is enhanced by intra-arterial thrombolysis, sonothrombolysis and clot-retrieval devices. Occasionally, reperfusion injury may lead to clinical deterioration. The search continues for effective neuroprotectants. Brain perfusion needs to be maintained through blood and intracranial pressure management. Hemicraniectomy for 'malignant' cerebral oedema reduces death and disability. Elevated glucose should be controlled and hypoxia alleviated. Public education of symptoms and the need for immediate presentation to a medical facility is needed. Stroke unit care reduces death and disability with little increase in cost. Current evidence supports urgent efforts to resuscitate the brain after stroke.

Multicenter external validation of the ABCD2 score in triaging TIA patients.

OBJECTIVES: A simple clinical score (ABCD(2) score) has been introduced to triage TIA patients with a high early risk of stroke. External validation studies have yielded inconsistent results regarding the predictive ability of the ABCD(2) score. We aimed to prospectively validate the former score in a multicenter case series study. METHODS: We prospectively calculated the ABCD(2) score (age [> or = 60 years: 1 point]; blood pressure [systolic >140 mm Hg or diastolic >90 mm Hg: 1[; clinical features [unilateral weakness: 2, speech disturbance without weakness: 1, other symptom: 0]; duration of symptoms [ <10 minutes: 0, 10-59 minutes: 1, > or = 60 minutes: 2]; diabetes mellitus [yes: 1]) in consecutive TIA patients hospitalized in 3 tertiary care neurology departments across 2 different racial populations (white and Asian). RESULTS: The 7-day and 90-day risks of stroke in the present case series (n = 148) were 8% (95% CI 4%-12%) and 16% (95% CI 10%-22%). The ABCD(2) score accurately discriminated between TIA patients with high 7-day (c statistic 0.72, 95% CI 0.57-0.88) and 90-day (c statistic 0.75, 95% CI 0.65-0.86) risks of stroke. The 90-day risk of stroke was 7-fold higher in patients with an ABCD(2) score >3 points (28%, 95% CI 18%-38%) than in patients with an ABCD(2) score < or = 3 points (4%, 95% CI 0%-9%). After adjustment for stroke risk factors, race, history of previous TIA, medication use before the index TIA and secondary prevention treatment strategies, an ABCD(2) score of >2 was associated with a nearly 5-fold greater 90-day risk of stroke (hazard ratio 4.65, 95% CI 1.04-20.84, p = 0.045). CONCLUSION: Our findings externally validate the usefulness of the ABCD(2) score in triaging TIA patients with a high risk of early stroke in a multiethnic sample of hospitalized patients. The present data support current guidelines endorsing the immediate hospitalization of patients with an ABCD(2) score >2.

Sonography as an aid to neurophysiological studies in diagnosing tarsal tunnel syndrome.

Diagnosing tarsal tunnel syndrome can be difficult because of varying clinical diagnostic criteria and equivocal physical signs. We present a case of tarsal tunnel syndrome where nerve conduction identified distal tibial neuropathy and high-resolution sonography was able to show nerve swelling within the tarsal tunnel.

Skin wrinkling for diagnosing small fibre neuropathy: comparison with epidermal nerve density and sympathetic skin response.

OBJECTIVE: To compare simple tests of small nerve fibre function with intraepidermal nerve fibre density (IENFD) in the evaluation of small fibre neuropathy (SFN). METHODS: Patients with idiopathic SFN of the hands were prospectively studied. Evaluation involved clinical examination, nerve conduction studies, sympathetic skin response (SSR) and skin wrinkling stimulated by water and EMLA (eutectic mixture of local anaesthetics). RESULTS: Of 21 patients, 16 (76%) had low IENFD, 15 (71%) impaired water-induced wrinkling, 14 (67%) impaired EMLA-induced wrinkling, and nine (43%) abnormal SSR. CONCLUSIONS: Stimulated skin wrinkling was nearly as sensitive as IENFD in diagnosing SFN, whereas SSR was of less use. Stimulated skin wrinkling is a useful supportive test when IENFD or other tests of small nerve fibre function are not available.

Bickerstaff's brainstem encephalitis: can it recur?

Bickerstaff's brain-stem encephalitis is usually a monophasic post-viral inflammatory illness characterized by progressive ophthalmoplegia, ataxia and disturbance of consciousness (or hyper-reflexia). Since the clinical spectrum of Bickerstaff encephalitis may overlap with the Miller-Fisher and Guillain-Barré syndromes, the presence of anti- GQ1b antibodies and abnormal brain MRI can help to support its diagnosis. However, absence of anti-GQ1b antibodies and normal MRI do not exclude the diagnosis, which remains based on clinical criteria and exclusion of other etiologies. We report a case of recurrent Bickerstaff's brainstem encephalitis with no identifiable antecedent illness, and overlapping features of Miller Fisher and Guillain-Barré syndromes, in the presence of negative anti-GQ1b antibodies and repeatedly normal MRI of the brain.

The NORSE (new-onset refractory status epilepticus) syndrome: defining a disease entity.

INTRODUCTION: To characterise a homogeneous group of patients with new-onset refractory status epilepticus (NORSE syndrome). MATERIALS AND METHODS: This is a descriptive, semiprospective review of all cases of NORSE syndrome seen between 2000 and 2004 at a tertiary care public hospital in Singapore. A review of the literature was performed to identify possible additional similar cases for comparison. RESULTS: Seven patients with NORSE syndrome were identified. Characterising features were female gender, young age, previous good health, cerebrospinal fluid pleocytosis (in 4), antecedent febrile illness (in 5), extraordinarily prolonged status epilepticus (average 32 days), failure of extensive investigations to reveal an underlying cause, catastrophic outcome as well as temporal lobe and leptomeningeal abnormality on brain magnetic resonance imaging. A review of the literature identified 12 similar patients, comprising both adults and children. CONCLUSIONS: Based on our patients and those described in the literature, we characterise the NORSE syndrome. Increased recognition of this clinical entity is needed to help delineate the underlying aetiology of this unique severe illness.