John W. Liang

Mobile Interventional Stroke Teams Lead to Faster Treatment Times for Thrombectomy in Large Vessel Occlusion

Background and Purpose— Endovascular recanalization treatment for acute ischemic stroke is a complex, time-sensitive intervention. Trip-and-treat is an interhospital service delivery model that has not previously been evaluated in the literature and consists of a shared mobile interventional stroke team that travels to primary stroke centers to provide on-site interventional capability. We compared treatment times between the trip-and-treat model and the traditional drip-and-ship model. Methods— We performed a retrospective analysis on 86 consecutive eligible patients with acute ischemic stroke secondary to large vessel occlusion who received endovascular treatment at 4 hospitals in Manhattan. Patients were divided into 2 cohorts: trip-and-treat (n=39) and drip-and-ship (n=47). The primary outcome was initial door-to-puncture time, defined as the time between arrival at any hospital and arterial puncture. We also recorded and analyzed the times of last known well, IV-tPA (intravenous tissue-type plasminogen activator) administration, transfer, and reperfusion. Results— Mean initial door-to-puncture time was 143 minutes for trip-and-treat and 222 minutes for drip-and-ship (P<0.0001). Although there was a trend in longer puncture-to-recanalization times for trip-and-treat (P=0.0887), initial door-to-recanalization was nonetheless 79 minutes faster for trip-and-treat (P<0.0001). There was a trend in improved admission-to-discharge change in National Institutes of Health Stroke Scale for trip-and-treat compared with drip-and-ship (P=0.0704). Conclusions— Compared with drip-and-ship, the trip-and-treat model demonstrated shorter treatment times for endovascular therapy in our series. The trip-and-treat model offers a valid alternative to current interhospital stroke transfers in urban environments.

Naltrexone for impulse control disorders in Parkinson disease: A placebo-controlled studyAuthor Response

Editors’ Note: Commenting on “Naltrexone for impulse control disorders in Parkinson disease: A placebocontrolled study,” Galduróz and colleagues argue that the negative findings of the study may be related to a confusion of concepts such as impulsivity, compulsivity, and craving. Furthermore, Liang and colleagues suggest that some impulse control disorders may be more responsive to naltrexone than others. Authors Weintraub et al. respond. Sethi and Strowd discuss the challenges of modern electronic medicine. —Chafic Karam, MD, and Robert C. Griggs, MD

Case of Cerebral Amyloid Angiopathy-Related Inflammation – Is the Absence of Cerebral Microbleeds A Good Prognostic Sign?

OBJECTIVE The aim of this study is to describe a case of pathologically proven cerebral amyloid angiopathy-related inflammation (CAA-I) without cerebral microbleeds (CMBs) and its clinical course. BACKGROUND CAA-I is an uncommon variant of cerebral amyloid angiopathy. Keys to diagnosis rely on the physicians awareness of this entity, CMBs on magnetic resonance imaging (MRI), an often favorable response to immunosuppression, and ultimately brain biopsy. CAA-I with no CMBs is rarely reported. RESULTS A 76-year-old woman presented with 4 weeks of headaches and was found to have visual neglect on the left part of the visual field. MRI of the brain showed sulcal/gyriform hyperintensity with associated leptomeningeal enhancement in the right occipital lobe on fluid-attenuated inversion recovery (FLAIR) imaging. No CMBs or large parenchymal FLAIR lesions were seen on MRI. Biopsy was consistent with CAA-I. The patients headaches resolved spontaneously and no immunosuppression was initiated. The patient remained asymptomatic for the 18 months of follow-up. CONCLUSIONS To the best of our knowledge, there has been only one previous case of pathology-proven CAA-I without CMBs reported and this was associated with a good prognosis. Lack of CMBs and/or large parenchymal FLAIR lesions may be a prognostic factor in this disease.

Comparison of Stroke Codes in the Emergency Room and Inpatient Setting

BACKGROUND Outcomes of acute stroke management are time dependent. Intravenous tissue plasminogen activator (t-PA) is indicated within 3-4.5 hours of symptom onset and endovascular intervention within 6 hours. Time to treatment may depend on the patients location. This study seeks to determine whether there is a difference in the timing of key aspects of stroke codes between the emergency room and the inpatient setting. METHODS Stroke codes ending in t-PA administration or endovascular intervention between 2010 and 2013 were included. Emergency room stroke codes were compared with those in the inpatient setting. Data were obtained from the Yarmon Stroke Center log. The variables were time to neurological evaluation, time to computed tomography (CT) scan, time to t-PA administration, time from CT scan to t-PA, and time to endovascular intervention. The variables were compared using the t test. RESULTS One hundred twenty-two stroke codes were included (106 from emergency room and 16 from inpatient setting). There was no difference in the time to neurological evaluation (P = .19). The time to CT scan and to t-PA administration was significantly increased in the inpatient group (P ≤ .001 and P = .01, respectively). There was no difference in the time from CT scan to t-PA (P = .09) and in the time to endovascular intervention (P = .21). CONCLUSIONS Our results show that in the inpatient setting, there was a significant delay in the time to CT scan and to t-PA administration and that the source of the delay is the time to CT scan.

Incidence of meningeal enhancement on brain MRI secondary to lumbar puncture

Background:Concern for reactive meningeal enhancement after lumbar puncture (LP) is a common reason for performing brain MRI prior to LP. We sought to determine actual incidence of unexplained meningeal enhancement after LP. Methods:We collected results from all contrasted brain MRIs in patients admitted to adult neurology at a New York City hospital over a 3-year period. We used electronic medical records to determine whether an LP had been done within 30 days prior to brain MRI. The control group comprised those brain MRIs not preceded by an LP within 30 days prior to imaging. Number of cases of unexplained meningeal enhancement was compared between groups using a Fisher exact test. We recorded variables such as number of LP attempts, needle size, amount of fluid removed, and days from LP to brain MRI. Results:From 2011 to 2013, there were 77 cases of LP prior to brain MRI and 707 controls (n = 784). Of the cases, 3 had meningeal enhancement, 1 (1.2%) of which was unexplained. Of the 707 controls, 36 had enhancement, and none was unexplained. The p value comparing unexplained enhancement in the cases vs controls was 0.098. Conclusions:Iatrogenic meningeal enhancement from prior LP that is not attributable to traumatic LP or intracranial hypotension is rare and not more common than in cases without a prior LP. Results suggest that the practice of delaying LP until after brain MRI might not be supported in cases where LP is necessary.

Clozapine Treatment for Impulse Control Disorders in Parkinson's Disease Patients: A Case Series

Impulse control disorders (ICDs) are nonmotor complications of dopaminergic medications characterized by problems in behavioral self‐control. Common management involves discontinuing or lowering dopaminergic medication, often producing motor worsening. We performed a retrospective chart review of Parkinsons disease (PD) patients treated with clozapine for ICDs. Four patients treated with clozapine for ICD were identified. Three patients were men. All 4 took dopaminergic medications at the time that ICDs developed; all received dopamine agonist therapy. ICDs included compulsive shopping, binge drinking, and hypersexuality. All 4 patients had complete resolution of symptoms while taking clozapine (12.5–37.5 mg). Two patients discontinued clozapine because of side effects. Larger studies are needed to further evaluate clozapines role in treating PD patients with ICD.

Sporadic Creutzfeldt-Jakob Disease With Unilateral Symptoms in the Setting of Metastatic Renal Cell Carcinoma

Introduction: Although it is not rare for magnetic resonance imaging findings in Creutzfeldt-Jakob disease to be asymmetric, unilateral clinical syndromes are uncommonly reported and may confound diagnosis. In addition, neurological paraneoplastic syndromes are not common in renal cell carcinoma, though there are cases reported, often without an offending antibody isolated. Case Report: A 66-year-old man was admitted with 1 month of left-sided numbness and “loss of control” of the left arm. Examination revealed action-induced irregular jerking movements of the left arm. Mental status testing was normal. Magnetic resonance imaging brain revealed patchy areas of restricted diffusion along the cerebral cortices. Screening computed tomographic scans revealed innumerable lung nodules compatible with metastases, as well as a renal mass consistent with renal cell carcinoma. Lumbar puncture was performed and cerebrospinal fluid was sent for paraneoplastic autoantibody evaluation and protein 14-3-3. Over the next week the patient developed dystonic posturing of the left arm, left leg jerking movements, a right arm action tremor, and cognitive impairment. Paraneoplastic autoantibodies were negative. Protein 14-3-3 was elevated and brain biopsy revealed spongiform encephalopathy with positive immunoblotting. The patient died about 2 months from symptom onset. Conclusions: Creutzfeldt-Jakob disease can present with entirely unilateral myoclonus and numbness, without specific complaints of cognitive impairment. Not every difficult or unclear neurological syndrome in a patient with metastatic cancer is a paraneoplastic syndrome.