Embolic Stroke in Setting of Iliac Vein Stenosis in an Avid Cyclist.

External iliac vein stenosis related to cycling has rarely been reported as a cause of deep vein thrombosis. Ischemic stroke occurring in this condition due to paradoxical embolism across a preexisting patent foramen ovale (PFO) has yet to be reported. Here we report a case of embolic ischemic strokes in a young, avid cyclist with no prior known vascular risk factors. A thorough cerebrovascular workup revealed a right-to-left shunt on transesophageal echocardiogram that prompted venous thrombosis evaluation. Pelvic MR venogram demonstrated a 3.5 cm high-grade stenosis of the right external iliac vein, concerning for possible prior thrombotic disease. His strokes were deemed most likely a result of paradoxical emboli originating in the pelvis at the site of right external iliac vein stenosis. The patient ultimately opted for PFO closure for secondary stroke prevention, as he wished to continue daily cycling. This case highlights the importance of neurohospitalists considering iliac vein stenosis as a potential cause of embolic stroke of undetermined source, especially in young patients who are avid cyclists, as part of a thorough vascular workup.

Marfan Syndrome Presenting as Spontaneous Coronary Artery Dissection and Arteriopathy.

INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a term used to define a spontaneous separation of the coronary artery wall not related to underlying risk factors, such as trauma or underlying atherosclerotic disease. While SCAD has a range of different etiologies, with fibromuscular dysplasia being the most common, most cases of SCAD have no concomitant arteriopathy. CASE REPORT: Here we describe a case of a patient who presented to our institution with SCAD and evidence of an asymptomatic arteriopathy involving extracranial segments of the carotid and vertebral arteries, later found to have a pathogenic variant in the FBN1 gene and ultimately diagnosed with Marfan syndrome. This has only been rarely described in the literature as an etiology for SCAD. CONCLUSION: Although rare, it is important to consider underlying connective tissue disorders in patients presenting with spontaneous coronary artery dissection and arteriopathy without underlying cardiovascular risk factors.

Vasculitis Presenting as Autonomic Failure.

INTRODUCTION: Granulomatosis with polyangiitis (GPA) is a vasculitic process that can cause neurological dysfunction in addition to characteristic sinus and pulmonary manifestations. This case report highlights the spectrum of nervous system manifestations and includes rarely reported autonomic and pituitary involvement. CASE REPORT: A 62-year-old woman presented with orthostatic intolerance, tachycardia, dry mouth, and temperature sensitivity; subsequent autonomic reflex study demonstrated widespread postganglionic sympathetic sudomotor, cardiovagal, and cardiovascular adrenergic impairment reflective of autonomic neuropathy and overall autonomic failure. Additional progressive symptoms included dysarthria, dysphagia, bilateral hearing loss, voice hoarseness, and right-sided facial numbness with multiple cranial neuropathies identified on neurological examination. The diagnosis of central diabetes insipidus was also confirmed. Pachymeningitis was present on brain magnetic resonance imaging. Pathologic review of the dural biopsy specimen revealed necrotizing granulomatous vasculitis consistent with GPA. She was treated with intravenous methylprednisolone and rituximab. Over the next 2 months, she had near-complete resolution of her symptoms with normalization on repeat autonomic testing. CONCLUSIONS: This is a unique GPA case presenting with autonomic failure and pituitary dysfunction with conclusive objective findings of autonomic dysfunction. Autonomic dysfunction and other disease manifestations were responsive to immunosuppressive therapy.

Noninvasive Neuromodulation in Migraine.

PURPOSE OF REVIEW: The past two decades has seen an influx of noninvasive neuromodulation devices aimed at treatment of various primary headache disorders, including cluster headache and migraine. This narrative review is to summarize the current options in noninvasive neuromodulation in migraine. RECENT FINDINGS: A variety of noninvasive neuromodulation devices have been FDA cleared and marketed for use in migraine, including single-pulse transcranial magnetic stimulation (sTMS), noninvasive vagal nerve stimulators (nVNS), and external trigeminal nerve stimulators (eTNS). Newer devices include peripheral electrical stimulation devices (PES), caloric stimulation, and others. Each has varying levels of evidence supporting its use in migraine, tolerability profiles, and access issues. Noninvasive neuromodulation devices can be beneficial when used in patients with migraine, with minimal side effects. As more devices are developed, approved, and marketed in the future, rigorous research on efficacy and safety remain a top priority.

Is Noninvasive Vagus Nerve Stimulation a Safe and Effective Alternative to Medication for Acute Migraine Control?

BACKGROUND: Noninvasive neuromodulation devices have been used for a variety of headache disorders, including cluster and migraine, since recently being cleared by the Federal Drug Administration. Although these devices have been touted as low-risk options for improved headache control, the data behind actual efficacy endpoints remain unclear. OBJECTIVE: To critically assess current evidence regarding the efficacy of the noninvasive vagus nerve stimulator (nVNS) device for acute migraine management. METHODS: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions.Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of headache. RESULTS: A randomized, double-blind, sham-controlled clinical trial was selected for critical appraisal. In this trial, the primary endpoint (pain freedom at 120 min after use of nVNS for first acute migraine attack) was not met when compared with sham device (30.4% for nVNS vs. 19.7% for sham; P=0.067). However, there were statistically significant differences found for various secondary endpoints favoring nVNS, such as pain freedom rates at 30 and 60 minutes, pain relief at 120 minutes, and mean percentage pain score reduction rates at 60 and 120 minutes. CONCLUSIONS: When comparing nVNS with sham, no statistically significant differences were found with regards to the primary endpoint of pain freedom at 120 minutes, although differences were found with various secondary endpoints and post hoc analysis. nVNS is likely a safe alternative to medications.

Telestroke Program Participation and Improvement in Door-To-Needle Times.

Background: Telestroke can provide indispensable expert stroke care for rural hospitals. The Stroke Telemedicine for Arizona Rural Residents program was developed in 2006 by Mayo Clinic to provide stroke expertise across the region. However, little data currently exist to determine whether this telestroke program had an impact on accepted acute stroke care metrics, such as door-to-needle time. Hypothesis: Participation of spoke sites in a telestroke program improves stroke care over time, as defined by currently accepted metrics, such as door-to-needle time. Methods: A retrospective analysis was performed on the telestroke database from Mayo Clinic Arizona between the years of 2011 to 2018. All patients with a diagnosis of acute ischemic stroke, who underwent a telestroke consultation and received intravenous alteplase were included in the analysis. Univariate linear regression was performed to look for associations between variables and defined outcomes. Results: A total of 563 patients were identified who met inclusion criteria. Average last-known normal to needle times decreased across all telestroke participating spoke sites from 176 to 147 min, with univariate linear regression showing a trend of decreased time of 3.4 min per year, which was statistically significant (p = 0.0042). Average door-to-needle times decreased from 112 to 81 min, with univariate linear regression modeling showing a decreasing trend of 3.7 min per year (p < 0.0001). Conclusions: Telestroke network participation may be associated with improved acute stroke care metrics over time, with the analysis illustrating improved last-known normal to needle and door-to-needle times among participating spoke sites.

Are Postprocedural Blood Pressure Goals Associated With Clinical Outcome After Mechanical Thrombectomy for Acute Ischemic Stroke?

Mechanical thrombectomy (MT) is the standard of care for patients who present with an acute ischemic stroke within 6 hours of symptom onset, and up to 24 hours in appropriately selected patients. However, optimal postoperative management of these patients remains uncertain, especially with regard to blood pressure control. To review the existing literature to define potential blood pressure goals in the immediate postoperative period in patients who undergo MT for acute ischemic stroke. The topic was defined through a clinical scenario and the subsequent development of a targeted clinical question. A literature search was performed, with relevant articles selected, one of which, a prospective observational study, was critically appraised. Participants included neurology residents and consultants, a medical librarian, clinical epidemiologists, as well as content experts from vascular neurology and interventional neuroradiology. Permissive hypertension (defined as <220/120 or <180/105 mm Hg as per the American Heart Association/American Stroke Association guidelines) may be harmful in the postoperative period following MT, especially in patients who were successfully recanalized. Moderate blood pressure control (<160/90) was found to be a predictor of improved 3-month mortality on multivariable logistic regression analysis in patients who sustained successful reperfusion [odds ratio (OR), 0.08; 95% confidence interval (CI), 0.01-0.054; P=0.01]. A 10 mm Hg increase in systolic blood pressure was found to result in a lower OR of having a favorable 3-month functional independence (OR, 0.70; 95% CI, 0.56-0.85; P=0.001) as well as higher rates of 3-month mortality (OR, 1.49; 95% CI, 1.18-1.88; P=0.001). Blood pressure goals in the immediate postoperative period in patients who undergo MT should differ than those who do not undergo MT, with data suggesting that lower blood pressure than permissive hypertension may be related to improved outcomes, especially in cases of successful reperfusion. However, current data are derived from observational studies; further studies, preferably in the form of randomized-controlled trials, are needed to further clarify the relationship between postoperative blood pressures and outcomes in this patient population.

Acute Right Middle Cerebral Artery Occlusion Resulting in Acute Systolic Heart Failure, Cerebral T-Waves, and QTc Prolongation: A Case Report.

INTRODUCTION: Acute cerebral injuries, such as cerebral ischemic or hemorrhagic events, have been repeatedly correlated with sudden electrocardiogram (ECG) changes, such as cardiac arrhythmias, QT prolongation, and T-wave inversion (the "cerebral T-wave"). Injuries to the insular cortex have been reported in the literature to result in such changes, possibly due to increased sympathetic tone to the cardiac system. CASE REPORT: A 65-year-old gentleman presented with an acute right middle cerebral artery territory infarction, and was found to have ECG abnormalities and left ventricular dysfunction, which improved after the acute phase of the stroke. CONCLUSIONS: Acute ischemic infarcts, particularly to the right insular cortex, can result in ECG abnormalities, such as QT prolongation and T-wave inversion, as well as acute systolic heart failure; all of which may be reversible after the acute phase of the stroke.

Availability of Network Psychiatrists Among the Largest Health Insurance Carriers in Washington, D.C.

OBJECTIVE: Lack of access to mental health treatment remains a significant problem in the United States, even after implementation of mental health parity legislation. This study examined availability of psychiatrists listed in insurance carrier network provider databases in the Washington, D.C., area. METHODS: Contact information was obtained for 1,184 psychiatrists listed in online directories for three of the largest insurance carriers serving the Washington, D.C., area. The "mystery shopper" method was used to assess the accuracy of listed contact information, new outpatient appointment availability, and average wait times for 50 psychiatrists randomly selected from each insurance directory. RESULTS: Most (77%) physicians were successfully contacted, meaning that someone answered the phone or returned a voice mail message, and 51% of the psychiatrists had working telephone numbers verified to be correct. Fifteen percent of the psychiatrists were accepting new outpatients with the target insurance, with average wait times of 19 days; only 7% were able to schedule an appointment within two weeks. CONCLUSIONS: Inaccuracy of insurance provider directories significantly affected the ability of patients to obtain timely mental care.