Infarcts of a Cardioembolic Source Mimicking Lacunar Infarcts: Case Series With Clinical and Radiological Correlation.

Lacunar strokes are the hallmark of cerebral small vessel disease. There are several well-established mechanisms for the pathogenesis of lacunar stroke, but the cardioembolic mechanism is not well-established. Three cases of acute ischemic stroke following elective cardiac and cerebral catheterization are reported. These cases had typical lacunar-looking infarcts on neuroimaging despite strong evidence of an embolic source with temporal correlation. Awareness of such findings and pathogenesis may help investigational workup and management of these patients.

Comparison of Outcomes of Ischemic Stroke Initially Imaged With Cranial Computed Tomography Alone vs Computed Tomography Plus Magnetic Resonance Imaging.

Importance: Patients with acute ischemic stroke often undergo magnetic resonance imaging (MRI) in addition to computed tomography (CT), but its association with clinical outcomes is uncertain. Objective: To assess whether clinical outcomes of patients with acute ischemic stroke with initial CT alone were noninferior to those with additional MRI. Design, Setting, and Participants: A retrospective observational propensity score-matched cohort study of clinical outcomes at discharge and 1 year for patients hospitalized with acute ischemic stroke was conducted at an academic medical center between January 2015 and December 2017. Data collection from an electronic medical record system performed from May 2020 through January 2022 was not completely blinded. Noninferiority margins were based on the designs of previous randomized clinical trials of ischemic stroke treatments. Statistical analysis was performed in January 2022. Participants were adults hospitalized with acute ischemic stroke with admission diagnosis based on CT. Exclusion criteria were primarily missing data. From 508 eligible patients, all 123 cases with additional MRI were propensity-score matched to 123 controls without. Exposure: MRI after initial diagnosis. Main Outcomes and Measures: Death or dependence at hospital discharge (modified Rankin Scale score of 3-6) and stroke or death occurring in survivors within 1 year after discharge. Results: Among 246 participants, the median age was 68 years (IQR, 58-78.8 years) and 131 (53.0%) were men. Death or dependence at discharge occurred more often in patients with additional MRI (59 of 123 [48.0%]) than in those with CT alone (52 of 123 [42.3%]; absolute difference, 5.7%; 95% CI, -6.7% to 18.1%), meeting the -7.50% criterion for noninferiority. Stroke or death within 1 year after discharge determined for 225 of 235 (96%) survivors occurred more often in patients with additional MRI (22 of 113 [19.5%]) than in those with CT alone (14 of 112 [12.5%]; relative risk, 1.14; 95% CI, 0.86-1.50), meeting the 0.725 relative risk criterion for noninferiority. Conclusions and Relevance: This propensity score-matched cohort study of patients hospitalized with acute ischemic stroke found that a diagnostic imaging strategy of initial CT alone was noninferior to initial CT plus additional MRI with regard to clinical outcomes at discharge and at 1 year. Further research is needed to determine which patients hospitalized with acute ischemic stroke benefit from MRI.

Multiple Listeria Abscesses in an Immunocompetent Patient.

Listeria monocytogenes is a ubiquitous organism that can potentially cause gastroenteritis and, less commonly, central nervous system infections. Brain abscess is rare and often associated with immunocompromised status. We report a case of multiple abscesses caused by Listeria in a previously immunocompetent elderly patient who developed a headache and left-sided hemiparesis over the course of days. Neuroimaging studies revealed multiple ring-enhancing lesions in the brain and midbrain territories. Blood culture, brain tissue aspirate, and cerebrospinal fluid nucleic acid amplification test were positive for Listeria. Extensive immunologic workup revealed no primary or secondary immunodeficiency disorders. After the initiation of antibiotics, the patient showed gradual clinical improvement and went to a skilled nursing facility after two weeks.

Sundown syndrome and symptoms of anxiety and depression in hospitalized elderly.

Sundown syndrome is characterized by the sudden appearance of neuropsychiatric symptoms such as agitation, confusion and anxiety in a chronologic fashion, usually during late afternoon or early evening. OBJECTIVE: To evaluate the prevalence of sundown syndrome in university hospital wards and its relationship with anxiety/depression symptoms, cognitive decline, and clinical and demographic variables. METHODS: We evaluated 70 patients admitted to the Lauro Wanderley University Hospital (HULW), João Pessoa-PB, Brazil. Data collection instruments were the Confusion Assessment Method (CAM), the Mini-Mental State Exam (MMSE) and the Hospital Anxiety and Depression Scale (HADS). RESULTS: Mean patient age was 68.4±6.4 years, 55.7% were male, 67.1% were illiterate or had incomplete primary education. It was observed that 14.3% of patients had delirium, 15.7% had cognitive deficits, while 21.4% and 18.6% had anxious and depressive symptoms, respectively. The age of patients with delirium (71.9±8.7) was significantly higher than those without (67.8±5.8). At 95% confidence, there was a significant difference in the groups with and without delirium for the MMSE and HADS-D scales. CONCLUSION: We verified the occurrence of delirium compatible with the sundown syndrome and associated with depressive symptoms and cognitive deficit, with no apparent relationship with infectious processes or fever, number of drugs used, hospital stay or anxious symptomatology.

A síndrome de Sundown é caracterizada pelo aparecimento súbito de sintomas neuropsiquiátricos como agitação, confusão e ansiedade de forma cronológica, geralmente no final da tarde ou no início da noite. OBJETIVO: Avaliar a prevalência da síndrome do por do sol em enfermarias de um hospital universitário e sua relação com sintomatologia depressivo-ansiosa, déficit cognitivo e variáveis clínicas e demográficas. MÉTODOS: Foram avaliados 70 pacientes admitidos nas enfermarias Hospital Universitário Lauro Wanderley (HULW), João Pessoa-PB, Brasil. Os instrumentos de coleta de dados foram a Escala de Avaliação de Quadros Confusionais (Confusion Assessment Method - CAM), o Mini-Exame do Estado Mental (MEEM) e a Escala Hospitalar de Ansiedade e Depressão (HADS). RESULTADOS: A média de idade de 68,4±6,4 anos, 55,7% do sexo masculino, 67,1% não alfabetizados ou com instrução fundamental incompleta. Observou-se que 14,3% dos pacientes tinham delirium, 15,7% tinham déficit cognitivo, enquanto 21,4% e 18,6% apresentavam sintomas ansiosos e depressivos, respectivamente. A idade dos pacientes com delirium (71,9±8,7) foi significativamente maior que a dos que não apresentavam este quadro (67,8±5,8). Com 95% de confiança, há diferença significativa nos grupos com e sem delirium em relação das escalas do MEEM e do HADS-D. CONCLUSÃO: Verificamos a ocorrência de delirium compatível com a síndrome do pôr do sol e associado com sintomas depressivos e déficit cognitivo, sem relação aparente com processo infeccioso ou febre, número de medicamentos em uso, permanência hospitalar e sintomatologia ansiosa.

Cranio-vertebral transition assessment by magnetic resonance imaging in a sample of a northeast Brazilian population.

METHODS: Cross-sectional analysis of craniometric parameters from individuals submitted to magnetic resonance at an outpatient imaging center between 2011 and 2012. RESULTS: Of 181 analyzed cases, the Welcker basal angle averaged 128.96º (SD 6.51), median distance between apex of the odontoid and Chamberlain's line was 2.27 mm (IQR -1.23-4.47) and the median clivus-canal angle was 150.5º (IQR 143.2-157.3). The Welcker basal angle was inversely correlated to the clivus-canal angle, and correlated to the distance between the apex of the odontoid and Chamberlain's line. CONCLUSION: There was a tendency to platibasia, basilar invagination and narrowing of the cranio-vertebral transition.

Cranio-vertebral transition assessment by magnetic resonance imaging in a sample of a northeast Brazilian population / Avaliação da transição crânio-vertebral por ressonância magnética em uma amostra da população do nordeste brasileiro

ABSTRACT Platybasia and basilar invagination are important alterations of the cranial-vertebral transition. Neuroimaging-based platybasia parameters include the Welcker basal angle, distance between the apex of the odontoid and Chamberlain's line, and the clivus-canal angle. This study aimed to measure and correlate these parameters in a sample from northeast Brazil. Methods Cross-sectional analysis of craniometric parameters from individuals submitted to magnetic resonance at an outpatient imaging center between 2011 and 2012. Results Of 181 analyzed cases, the Welcker basal angle averaged 128.96º (SD 6.51), median distance between apex of the odontoid and Chamberlain's line was 2.27 mm (IQR -1.23-4.47) and the median clivus-canal angle was 150.5º (IQR 143.2-157.3). The Welcker basal angle was inversely correlated to the clivus-canal angle, and correlated to the distance between the apex of the odontoid and Chamberlain's line. Conclusion There was a tendency to platibasia, basilar invagination and narrowing of the cranio-vertebral transition.

RESUMO Platibasia e invaginação basilar são importantes alterações da transição craniovertebral. Existem parâmetros importantes obtidos pela neuroimagem, como o ângulo basal de Welcker, distância do ápice do odontoide à linha de Chamberlain e o ângulo clivo-canal. Este estudo procurou medir e correlacioná-los em uma amostra do Nordeste Brasileiro. Métodos Estudo transversal com medidas de indivíduos submetidos a ressonância magnética craniana em um centro de diagnóstico por imagem entre 2011 e 2012. Resultados Dos 181 casos analisados, o ângulo basal de Welcker teve média 128.96º (DP 6.51), a distância do ápice do odontoide à linha de Chamberlain obteve mediana 2.27 mm (IIQ -1.23-4.47) e o ângulo clivo-canal mediano foi 150.5º (IIQ 143.2-157.3). O ângulo basal de Welcker foi inversamente correlacionado com o ângulo clivo-canal e diretamente correlacionado com a distância do ápice do odontoide à linha de Chamberlain. Conclusão Houve uma tendência a platibasia, invaginação basilar e estreitamento da transição craniovertebral, que poderiam ser influenciados pela natureza multirracial e por fatores antropológicos da população estudada.

Sundown syndrome and symptoms of anxiety and depression in hospitalized elderly / Síndrome do pôr do sol e sintomas de ansiedade e depressão em idosos hospitalizados

ABSTRACT Sundown syndrome is characterized by the sudden appearance of neuropsychiatric symptoms such as agitation, confusion and anxiety in a chronologic fashion, usually during late afternoon or early evening. Objective: To evaluate the prevalence of sundown syndrome in university hospital wards and its relationship with anxiety/depression symptoms, cognitive decline, and clinical and demographic variables. Methods: We evaluated 70 patients admitted to the Lauro Wanderley University Hospital (HULW), João Pessoa-PB, Brazil. Data collection instruments were the Confusion Assessment Method (CAM), the Mini-Mental State Exam (MMSE) and the Hospital Anxiety and Depression Scale (HADS). Results: Mean patient age was 68.4±6.4 years, 55.7% were male, 67.1% were illiterate or had incomplete primary education. It was observed that 14.3% of patients had delirium, 15.7% had cognitive deficits, while 21.4% and 18.6% had anxious and depressive symptoms, respectively. The age of patients with delirium (71.9±8.7) was significantly higher than those without (67.8±5.8). At 95% confidence, there was a significant difference in the groups with and without delirium for the MMSE and HADS-D scales. Conclusion: We verified the occurrence of delirium compatible with the sundown syndrome and associated with depressive symptoms and cognitive deficit, with no apparent relationship with infectious processes or fever, number of drugs used, hospital stay or anxious symptomatology.

RESUMO A síndrome de Sundown é caracterizada pelo aparecimento súbito de sintomas neuropsiquiátricos como agitação, confusão e ansiedade de forma cronológica, geralmente no final da tarde ou no início da noite. Objetivo: Avaliar a prevalência da síndrome do por do sol em enfermarias de um hospital universitário e sua relação com sintomatologia depressivo-ansiosa, déficit cognitivo e variáveis clínicas e demográficas. Métodos: Foram avaliados 70 pacientes admitidos nas enfermarias Hospital Universitário Lauro Wanderley (HULW), João Pessoa-PB, Brasil. Os instrumentos de coleta de dados foram a Escala de Avaliação de Quadros Confusionais (Confusion Assessment Method - CAM), o Mini-Exame do Estado Mental (MEEM) e a Escala Hospitalar de Ansiedade e Depressão (HADS). Resultados: A média de idade de 68,4±6,4 anos, 55,7% do sexo masculino, 67,1% não alfabetizados ou com instrução fundamental incompleta. Observou-se que 14,3% dos pacientes tinham delirium, 15,7% tinham déficit cognitivo, enquanto 21,4% e 18,6% apresentavam sintomas ansiosos e depressivos, respectivamente. A idade dos pacientes com delirium (71,9±8,7) foi significativamente maior que a dos que não apresentavam este quadro (67,8±5,8). Com 95% de confiança, há diferença significativa nos grupos com e sem delirium em relação das escalas do MEEM e do HADS-D. Conclusão: Verificamos a ocorrência de delirium compatível com a síndrome do pôr do sol e associado com sintomas depressivos e déficit cognitivo, sem relação aparente com processo infeccioso ou febre, número de medicamentos em uso, permanência hospitalar e sintomatologia ansiosa.