Outcomes Among Patients With Reversible Cerebral Vasoconstriction Syndrome: A Nationwide United States Analysis.

BACKGROUND AND PURPOSE: Reversible cerebral vasoconstriction syndrome (RCVS) is a well-established cause of stroke, but its demographics and outcomes have not been well delineated. METHODS: Analysis of the United States Nationwide Inpatient Sample database (2016-2017) to characterize the frequency of hospitalizations for RCVS, demographic features, inpatient mortality, and discharge outcomes. RESULTS: During the 2-year study period, 2020 patients with RCVS were admitted to Nationwide Inpatient Sample hospitals, representing 0.02 cases per 100 000 national hospitalizations. The mean age at admission was 47.6 years, with 85% under 65 years of age, and 75.5% women. Concomitant neurological diagnoses during hospitalization included ischemic stroke (17.1%), intracerebral hemorrhage (11.0%), subarachnoid hemorrhage (32.7%), seizure disorders (6.7%), and reversible brain edema (13.6%). Overall, 70% of patients were discharged home, 29.7% discharged to a rehabilitation facility or nursing home and 0.3% died before discharge. Patient features independently associated with the poor outcome of discharge to another facility or death were advanced age (odds ratio [OR], 1.04 [95% CI, 1.03-1.04]), being a woman (OR, 2.45 [1.82-3.34]), intracerebral hemorrhage (OR, 2.91 [1.96-4.31]), ischemic stroke (OR, 5.72 [4.32-7.58]), seizure disorders (OR, 2.61 [1.70-4.00]), reversible brain edema (OR, 6.26 [4.41-8.89]), atrial fibrillation (OR, 2.97 [1.83-4.81]), and chronic kidney disease (OR, 3.43 [2.19-5.36]). CONCLUSIONS: Projected to the entire US population, >1000 patients with RCVS are hospitalized each year, with the majority being middle-aged women, and about 300 required at least some rehabilitation or nursing home care after discharge. RCVS-related inpatient mortality is rare.

Vertebral Artery Dissection in a Woman Due to Golf: An Under Recognized Etiology.

INTRODUCTION: Traditionally, spontaneous cervical artery dissections have been associated with violent, sudden neck movements. These events are a significant cause of stroke related morbidity, particularly in young people. Only a handful of cases of golf-induced vertebral artery dissection (VAD) have been described, and the discussion has primarily focused on middle-aged men. Despite the discussion focused on this demographic, women are participating in golf at higher rates than ever before, and have a higher risk for developing VAD. CASE REPORT: A 41-year-old woman presented to our hospital with sharp neck pain, dizziness, and ptosis after swinging a driver during a morning round of golf. Imaging demonstrated a right V3/V4 VAD and subsequent ischemic infarction. After administration of tissue plasminogen activator she had abrupt change in mental status with seizure-like activity. She underwent angiogram and mechanical thrombectomy, and was started in heparin 24 hours post-tissue plasminogen activator. This was subsequently changed to low-dose aspirin following thalamic petechial hemorrhage. She was discharged from the hospital after a few days with only minor deficits. We will discuss mechanism, treatment, and outcomes of VAD in context of this case. CONCLUSION: This patient is the first woman in the literature to suffer from VAD as a result of playing golf. The twisting motion of the head and neck in a golf swing may be a risk factor for dissection and subsequent development of stroke. As a result of increased female participation in golf, we expect to see increased incidence of women presenting with "golfer's stroke" in coming years.

Treating Paroxysmal Sympathetic Hyperactivity With Enteral Baclofen in Anoxic Brain Injury.

INTRODUCTION: Paroxysmal sympathetic hypersensitivity (PSH) has become more frequently recognized in patients with severe neurological brain injury. Left untreated, PSH has been associated with poor neurological outcomes. Currently, most therapeutic options are circumstantial with evidence stemming from subjective case reports. CASE SERIES: Two young females were admitted after cardiac arrest and found to have anoxic brain injury with subsequent PSH. Initial treatment was targeted at relief of the hyperadrenergic symptoms, which included bromocriptine, propranolol, opioids and benzodiazepines. These therapies were minimally effective, and the patients remained comatose. After initiation of enteral baclofen treatment, they exhibited drastic reduction of PSH symptoms and became alert and interactive. After a 6-week hospital stay, they were both discharged to long-term rehabilitation centers. CONCLUSION: This case series reviews the current therapies used for PSH and discusses 2 patients with uncontrolled PSH secondary to anoxic brain injury. Both patients arose from coma and had significant symptomatic improvement with enteral baclofen treatment. Thus, enteral baclofen should be considered as a primary treatment for PSH to prevent sustained symptoms and prolonged hospitalizations.

A fatal case of Immune thrombocytopenia secondary to the immune checkpoint inhibitor ipilimumab in a patient with BRAF wild type metastatic melanoma.

INTRODUCTION: Immune checkpoint inhibitors have revolutionized the field of oncology in recent years. Ipilimumab is a monoclonal antibody that targets the protein cytotoxic T-lymphocyte 4, which is involved in the inhibition of cytotoxic T-lymphocytes. When uninhibited, cytotoxic T-lymphocytes can act to recognize and kill cancer cells. This increased activity of immune cells can inadvertently destroy healthy tissue leading to a class of side effects known as immune-related adverse events. Immune thrombocytopenia purpura secondary to checkpoint inhibitors is an uncommon complication (<1%) and in most instances resolve spontaneously without aggressive treatment. CASE REPORT: We present a case of immune thrombocytopenia purpura developing in a patient recently started on ipilimumab for BRAF wild-type metastatic melanoma. The patient presented to his primary oncologist with confusion and lethargy. Subsequent blood work revealed a platelet count of 16,000 ng/mL. The patient was transferred to the emergency department where a computed tomography scan revealed bilateral frontal lobe hemorrhages. The patient was admitted to the intensive care unit for further management. MANAGEMENT AND OUTCOME: The patient received IV immunoglobulins at 1 g/kg every 24 h in addition to IV Decadron 40 mg daily. In addition, the patient continued to receive significant platelet transfusions. The patient's platelet count recovered to 78,000 ng/mL (baseline for this patient > 130,000 ng/mL.) The patient developed worsening mental status and was found to have significant increase in previously found bilateral frontal hemorrhages. The patient was transitioned to comfort measures only due to very poor prognosis and passed away in hospice care. DISCUSSION: Checkpoint inhibitors have provided durable responses in multiple cancers that previously had a paucity of treatment options. This case demonstrates that immune thrombocytopenia purpura is a possible adverse event of these therapies and thus platelet monitoring should be included in all patients.

The neuron specific enolase (NSE) ratio offers benefits over absolute value thresholds in post-cardiac arrest coma prognosis.

INTRODUCTION: Serum neuron-specific enolase (NSE) levels have been shown to correlate with neurologic outcome in comatose survivors of cardiac arrest but use of absolute NSE thresholds is limited. This study describes and evaluates a novel approach to analyzing NSE, the NSE ratio, and evaluates the prognostic utility of NSE absolute value thresholds and trends over time. METHODS: 100 consecutive adult comatose cardiac arrest survivors were prospectively enrolled. NSE levels were assessed at 24, 48, and 72 h post-arrest. Primary outcome was the Glasgow Outcome Score (GOS) at 6 months post-arrest; good outcome was defined as GOS 3-5. Absolute and relative NSE values (i.e. the NSE ratio), peak values, and the trend in NSE over 72 h were analyzed. RESULTS: 98 patients were included. 42 (43%) had a good outcome. Five good outcome patients had peak NSE >33 µg/L (34.9-46.4 µg/L). NSE trends between 24 and 48 h differed between outcome groups (decrease by 3.0 µg/L (0.9-7.0 µg/L) vs. increase by 13.4 µg/L (-3.7 to 69.4 µg/L), good vs. poor, p = 0.004). The 48:24 h NSE ratio differed between the good and poor outcome groups (0.8 (0.6-0.9) vs. 1.4 (0.8-2.5), p = 0.001), and a 48:24 h ratio of ≥1.7 was 100% specific for poor outcome. CONCLUSIONS: The NSE ratio is a unique method to quantify NSE changes over time. Values greater than 1.0 indicate increasing NSE and may be reflective of ongoing neuronal injury. The NSE ratio obviates the need for an absolute value cut-off.