Daniel J. Miller

Outpatient cardiac telemetry detects a high rate of atrial fibrillation in cryptogenic stroke.

BACKGROUNDnThe etiology of cerebral ischemia is undetermined in one-third of patients upon discharge. Occult paroxysmal atrial fibrillation (PAF) is considered a potential etiology. A high rate of PAF detection with 21-day mobile cardiac outpatient telemetry (MCOT) has been reported in two small studies. Optimal monitoring duration and factors predicting PAF have not been adequately defined.nnnMETHODSnWe performed a retrospective analysis on patients evaluated by MCOT monitoring within 6 months of a cryptogenic stroke or TIA. Multivariate analysis with survival regression methods was performed using baseline characteristics to determine predictive risk factors for detection of PAF. Kaplan-Meier estimates were computed for 21-day PAF rates.nnnRESULTSnWe analyzed 156 records; PAF occurred in 27 of 156 (17.3%) patients during MCOT monitoring of up to 30 days. The rate of PAF detection significantly increased from 3.9% in the initial 48 h, to 9.2% at 7 days, 15.1% at 14 days, and 19.5% by 21 days (p<0.05). Female gender, premature atrial complex on ECG, increased left atrial diameter, reduced left ventricular ejection fraction and greater stroke severity were independent predictors of PAF detection on multivariate analysis with strongest correlation seen for premature atrial complex on ECG (HR 13.7, p=0.001).nnnCONCLUSIONnMCOT frequently detects PAF in patients with cryptogenic stroke and TIA. Length of monitoring is strongly associated with detection of PAF, with an optimal monitoring period of at least 21 days. Of the predictors of PAF detection, the presence of premature atrial complexes on ECG held the strongest correlation with PAF.

Safety and outcomes in stroke mimics after intravenous tissue plasminogen activator administration: a single-center experience.

BACKGROUNDnPatients with symptoms that impersonate a stroke but are later found to have an alternate diagnosis are termed stroke mimics. Stroke mimics treated with intravenous (IV) tissue plasminogen activator (t-PA) are exposed to hemorrhagic complications without benefit. The objective of this study is to describe the characteristics, safety, and outcomes of stroke mimic patients treated with t-PA within 4.5 hours.nnnMETHODSnAll patients hospitalized after IV t-PA treatment at a tertiary care hospital and primary stroke center from January 2008 through December 2011 were reviewed. Stroke mimics were determined by review of clinical and imaging findings. Stroke mimics are described and compared with acute ischemic stroke patients for demographics, clinical characteristics, and bleeding complications.nnnRESULTSnWe identified 38 stroke mimic (12%) and 285 ischemic stroke (88%) t-PA-treated patients. Compared with ischemic stroke patients, mimic patients were younger, more often female, and reported a history of stroke more often. There were no differences in race, baseline stroke scale, or onset to treatment time. There were no intracerebral hemorrhages or deaths in the mimic patients but there were 2 systemic hemorrhages (5.2%).nnnCONCLUSIONSnTreatment of mimic patients with IV t-PA appears to be safe in this cohort. Concern for intracerebral hemorrhage in mimic patients need not dissuade clinicians from administering t-PA when significant concern for ischemic etiology exists.

Opsoclonus as a manifestation of Hashimoto's encephalopathy.

We present a 59-year-old male with early manifestation of opsoclonus associated with gait ataxia as a rare clinical presentation of Hashimotos encephalopathy. Empiric use of intravenous immunoglobulin followed by intravenous high dose methylprednisolone was initiated with subsequent remittance of opsoclonus, encephalopathy, ataxia, and tremor. Extensive workup for infectious, autoimmune, and paraneoplastic etiologies were undertaken and all studies were negative. Thyroglobulin antibodies (312 U/mL) and thyroid peroxidase antibodies (457 U/mL) were elevated (normal <60 U/mL) with a euthyroid state (thyroid stimulating hormone 3.13 μIU/mL). Three months after intravenous steroid therapy, the concentrations of thyroglobulin and thyroid peroxidase antibodies were retested and found to have decreased considerably. Thus, with steroid therapy, the patients opsoclonus and encephalopathy improved. We have presented a patient with a rare case of opsoclonus as the principal presenting feature of Hashimotos encephalopathy that was incompletely responsive to intravenous immunoglobulin and resolved with corticosteroids. This report underscores the importance for clinical practitioners to maintain a high index of suspicion for Hashimotos encephalopathy in cases of opsoclonus, especially when accompanied by an atypical presentation.

The Evolution and Application of Cardiac Monitoring for Occult Atrial Fibrillation in Cryptogenic Stroke and TIA

Opinion statementThe evaluation of the stroke and transient ischemic attack (TIA) patient has been historically predominated by the initial evaluation in the hospital setting. As the etiology of stroke has eluded us in approximately one third of all acute events, the medical community has been eager to seek the answer to this mystery. In recent years, we have seen an explosion of innovations and trends allowing for a more detailed post stroke assessment strategy aimed at the identification of occult atrial fibrillation as the etiologic cause for the cryptogenic event. This has been achieved through the evolution and aggressive application and study of prolonged and advanced cardiac monitoring. This review is aimed to clarify and elucidate the standard and novel cardiac monitoring methods that have become available for use by the medical community and expected in the higher level care of cryptogenic stroke and TIA patients. These cardiac monitoring methods and devices are as heterogeneous as our patient population and have their own advantages and disadvantages. Many factors may be taken into consideration in choosing the appropriate cardiac monitoring method and are highlighted for consideration in this review. With a judicious approach to investigating the cryptogenic stroke population, and applying a wealth of novel treatment options, we may move forward into a new era of stroke prevention.

Fibromuscular dysplasia unraveled: The pulsation-induced microtrauma and reactive hyperplasia theory

INTRODUCTIONnFibromuscular dysplasia (FMD) is a relatively uncommon, non-inflammatory, non-atherosclerotic vascular condition of unknown etiology. There have been no major advancements in understanding FMD in the past 30-40yrs. We hypothesize that the vascular changes seen in FMD are a direct result of recurrent mechanical trauma in susceptible vessels and reflect a compensatory response to recurrent pulsation-induced mechanical trauma.nnnMETHODSnRadiology records at a large tertiary care medical center were queried for cases of cervical carotid FMD. Cases with viewable sequential angiographic evidence of FMD were selected and analyzed for degree of vessel tortuosity, FMD type, degree of vessel movement, and association with the FMD lesion. Images were independently analyzed by 1 neurologist and 2 neuroradiologists.nnnRESULTSnTwenty-four carotid vessels in fourteen patients were identified to have FMD, 100% of patients were female, average age was 58.43±8.72yrs (range 45-73), 35.7% were black, 35.7% had HTN, 7.14% had CKD and 7.14% used tobacco in the past year. Associated findings included aneurysms and dissections. All but 1 patient had at least mild vessel tortuosity, and 28.6% were moderate or severe. All but 1 patient had at least some pulsation-like vessel movement, 16.7% had significant movement, and all movement was focally associated with the FMD abnormality.nnnCONCLUSIONnPulsatile vascular movements were observed in high frequency and in high association with FMD. We propose a theoretical connection between the pulsation-induced movement and a process of reactive vascular hyperplasia and fibrosis responsible for the FMD phenotype and is consistent with previous findings.

Indecision in the clinical practice of anticoagulation for brief atrial arrhythmias after cryptogenic stroke

INTRODUCTIONnLong-term cardiac monitoring has a substantial yield for paroxysmal atrial fibrillation (PAF) detection in cryptogenic stroke or transient ischemic attack (TIA) patients; however, many of these episodes were brief. We analyzed treatment decisions taken by the clinicians regarding anticoagulation in these short-duration PAF patients.nnnMETHODSnWe performed a retrospective analysis on all mobile cardiac outpatient telemetry records between June 2009 and January 2012, initiated by neurologists from a large tertiary care institution stroke center.nnnRESULTSnIn all, 39 patients were found to have atrial fibrillation (AF), and their records were reviewed. AF episodes were categorized as less than 30 seconds in 24 (62%) patients and 30 seconds or more in 15 (38%) patients. Among the 16 patients without a cardiology evaluation, the rate of anticoagulation was high and did not differ for patients with short AF (90%, 9 of 10) and long AF (83%, 5 of 6) (P>.99). However, among the 23 patients with a cardiology evaluation, the difference in rates of anticoagulation was significant between patients with short AF (43%, 6 of 14) and long AF (89%, 8 of 9) (P=.039).nnnCONCLUSIONnOur study demonstrates the differences in anticoagulant prescribing practices between neurologists and cardiologists and the inherent indecision these findings have produced. Further study is needed to better define the risks and benefits associated with anticoagulation of brief episodes of atrial arrhythmias lasting less than 30 seconds in patients with cryptogenic stroke or TIA.

Prolonged cardiac monitoring after cryptogenic stroke superior to 24 h ECG in detection of occult paroxysmal atrial fibrillation

Commentary on : Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Eng J Med 2014;370:2467–77.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4]nnStroke remains a prevalent and devastating condition for many people across the world, it is a leading cause of disability and is associated with significant monetary and social losses, yet is considered to be a largely preventable disease. One-third of all strokes are considered cryptogenic after initial diagnostic evaluations. Cryptogenic stroke has been identified, only recently, as an important area of additional investigation. Part of the EMBRACE trial, Gladstone and colleagues’ study adds to mounting evidence that prolonged cardiac monitoring is needed to identify paroxysmal atrial fibrillation (PAF) in patients with cryptogenic stroke.nnIn this open-label, multicenter trial in Canada, 572 patients over the age of 55 with a recent cryptogenic stroke or transient ischaemic attack (TIA) were randomised to conventional 24u2005h ECG monitoring (Holter monitor) versus 30-day non-invasive, ambulatory ECG …nn [1]: {openurl}?query=rft.jtitle%253DN%2BEng%2BJ%2BMed%26rft.volume%253D370%26rft.spage%253D2467%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJMoa1311376%26rft_id%253Dinfo%253Apmid%252F24963566%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actxn [2]: /lookup/external-ref?access_num=10.1056/NEJMoa1311376&link_type=DOIn [3]: /lookup/external-ref?access_num=24963566&link_type=MED&atom=%2Febmed%2F19%2F6%2F235.atomn [4]: /lookup/external-ref?access_num=000337804400004&link_type=ISI

Symptomatic palatal tremor of cortical origin due to stroke.

Palatal tremor (PT) is usually considered a movement disorder that presents with recurring rhythmic contractions of the soft palate. The inferior olive shows a characteristic pseudohypertrophy secondary to brainstem lesions in the triangle of Mollaret and Guillain that interrupt dentato-olivary and tegmental pathways. We report a 35-year-old man with a history of uncontrolled hypertension who presented to the emergency department with PT after a left middle cerebral artery ischemic stroke. The diagnostic work-up consisted of brain MRI, which revealed restricted diffusion over the left frontoparietal lobes without involvement of the brainstem. During hospitalization, the patient reported two brief episodes of soft palate and base-of-the-tongue high-frequency, low-amplitude and rhythmic tremor that resolved after intravenous administration of lorazepam. A 2-hour video electroencephalogram showed no abnormalities. After initiation of levetiracetam therapy, no further spells were reported by the patient. At the 2-month follow-up, the patient had had no episodes of stereotypical PT or upper limb tremors since discharge. This report provides further evidence of the central role of the cortex in the generation of PT. The cortical origin of symptomatic palatal tremor (SPT) should be considered in patients presenting after an acute ischemic insult, particularly if there is no evidence of a brainstem lesion. Potential causes of SPT of cortical origin include focal epilepsy and diaschisis.

Cerebrovascular injuries found in acute type B aortic dissections are associated with blood pressure derangements and poor outcome

OBJECTIVEnCerebrovascular injury (CVI) is a recognized but underappreciated complication of acute type B aortic dissection (ATBAD). This study was performed to determine risk factors for CVI associated with ATBAD and, in particular, the possible contributory role of aggressive anti-impulse therapy.nnnMETHODSnA retrospective review of all patients presenting to a tertiary medical center with an ATBAD between January 2003 and October 2012 was conducted. All CVIs were adjudicated by a vascular neurologist and assigned a probable cause. The initial intensity of anti-impulse therapy was defined as the difference in mean arterial pressure (ΔMAP) from presentation to subsequent admission to the intensive care unit.nnnRESULTSnA total of 112 patients were identified. The average age was 61xa0years; 64% were male, and 59% were African American. Twenty patients required operative intervention (14 thoracic endovascular aortic repairs and 6 open). CVI occurred in 13 patients (11.6%): 9 were hypoperfusion related (6 diffuse hypoxic brain injuries and 3 watershed infarcts), 2xa0were procedure related (both thoracic endovascular aortic repairs), 1 was an intracranial hemorrhage on presentation, and 1 was a probable embolic stroke on presentation. CVI patients had demographics and comorbidities comparable to those of the non-CVI patients. CVI was associated with operative intervention (54% vs 13%; Pxa0= .002). Thirty-day mortality was significantly higher in CVI patients (54% vs 6%; Pxa0< .001). Patients who suffered a hypoperfusion brain injury had a higher MAP on presentation to the emergency department (142xa0mm Hg vs 120xa0mm Hg; Pxa0= .034) and a significantly greater reduction in MAP (ΔMAP 49xa0mm Hg vs 15xa0mm Hg; Pxa0< .001) by the time they reached the intensive care unit compared with the non-CVI patients.nnnCONCLUSIONSnIn our series, CVI in ATBAD is more frequent than previously reported and is associated with increased mortality. The most common causes are related to cerebral hypoperfusion. Higher MAP on presentation and greater decline in MAP are associated risk factors for hypoperfusion-related CVI. A less aggressive approach to lowering MAP in ATBAD warrants further study in an attempt to reduce CVI in ATBAD.

Three-dimensional modeling of Eagle syndrome

A 63-year-old man presented with transient episodes of left-hand weakness and right-eye vision loss following a lengthy airplane trip. The patient had reported right neck pain after sleeping awkwardly on the flight. Carotid dissection, paradoxical embolism, atherosclerotic occlusion, and thrombotic occlusion were considered possible etiologies of the associated carotid occlusion. Following a period of anticoagulation, a subsequent CT angiography (figure 1, A–C) revealed findings consistent with the styloid-carotid artery, or Eagle, syndrome.1 A 3-dimensional model was subsequently created (figure 2, A and B) utilizing a 3D printer, which provided the most versatile, safe, and cost-efficient option2 to visualize the patients unique anatomy and plan for surgical intervention.