Kaustubh Limaye

Thrombolysis in Ischemic Stroke Without Arterial Occlusion at Presentation

Background and Purpose— None of the randomized trials of intravenous tissue-type plasminogen activator reported vascular imaging acquired before thrombolysis. Efficacy of tissue-type plasminogen activator in stroke without arterial occlusion on vascular imaging remains unknown and speculative. Methods— We performed a retrospective, multicenter study to collect data of patients who presented to participating centers during a 5-year period with ischemic stroke diagnosed by clinical examination and MRI and with imaging evidence of no vascular occlusion. These patients were divided into 2 groups: those who received thrombolytic therapy and those who did not. Primary outcome measure of the study was excellent clinical outcome defined as modified Rankin Scale of 0 to 1 at 90 days from stroke onset. Secondary outcome measures were good clinical outcome (modified Rankin Scale, 0–2) and perfect outcome (modified Rankin Scale, 0). Safety outcome measures were incidence of symptomatic intracerebral hemorrhage and poor outcome (modified Rankin Scale, 4–6). Results— A total of 256 patients met study criteria, 103 with thrombolysis and 153 without. Logistic regression analysis showed that patients who received thrombolysis had more frequent excellent outcomes with odds ratio of 3.79 (P<0.01). Symptomatic intracerebral hemorrhage was more frequent in thrombolysis group (4.9 versus 0.7%; P=0.04). Thrombolysis led to more frequent excellent outcome in nonlacunar group with odds ratio 4.90 (P<0.01) and more frequent perfect outcome in lacunar group with odds ratio 8.25 (P<0.01). Conclusions— This study provides crucial data that patients with ischemic stroke who do not have visible arterial occlusion at presentation may benefit from thrombolysis.

Interfacility Transfer Directly to the Neuroangiography Suite in Acute Ischemic Stroke Patients Undergoing Thrombectomy

Background and Purpose— In patients identified at referring facilities with acute ischemic stroke caused by a large vessel occlusion, bypassing the emergency department (ED) with direct transport to the neuroangiography suite may safely shorten reperfusion times. Methods— We conducted a single-center retrospective review of consecutive patients transferred to our facility for consideration of endovascular therapy. Patients were identified as admitted directly to the neuroangiography suite (DAN), transferred to the ED before intra-arterial therapy (ED-IA), and transferred to the ED but did not receive IA therapy (ED-IV). Results— A retrospective review of a prospectively maintained database of transfer patients between January 2013 and October 2016 with large vessel occlusions identified 108 ED-IV patients and 261 patients who underwent mechanical thrombectomy (DAN=111 patients and ED-IA=150 patients). There were no differences in baseline characteristics among the 3 groups. The median computed tomography ASPECTS (Alberta Stroke Program Early CT Score) was lower in the ED-IV group versus the ED-IA and DAN groups (8 versus 9; P=0.001). In the DAN versus ED-IA cohort, there were comparable rates of TICI2b/3 recanalization and access to recanalization time. There was significantly faster hospital arrival to groin access time in the DAN cohort (81 minutes versus 22 minutes; P=0.001). Functional independence at 90 days was comparable in the DAN versus ED-IA cohorts but worse in the ED-IV group (43% versus 44% versus 22%; P=0.001). Conclusions— DAN is safe, feasible, and associated with faster times of hospital arrival to recanalization. The clinical benefit of this approach should be assessed in a prospective randomized trial.

Hypertrophic olivary degeneration after cerebellar hemorrhage

We present a striking example of hypertrophic olivary degeneration after cerebellar hemorrhage. This case highlights some important teaching points: unique response of the inferior olivary nucleus to de-afferentation, anatomy of Mollarets triangle and clinical manifestations of disruption in Mollarets triangle. The purpose of this teaching case is to highlight a rare but important post-stroke complication.

Not everything that worsens on standing is intracranial hypotension

Objective: We are reporting a patient with pneumocephalus presenting as orthostatic headache. Introduction: Orthostatic headache is a prototypical manifestation of post-dural puncture headache (PDPH). A less common and under-recognized cause of post-epidural headache is pneumocephalus, which is characterized by a lack of relief by lying down. However, in a patient with coexisting PDPH, improvement of headache after lying down cannot reliably rule out the possibility of pneumocephalus. Design/Methods: Case report and literature review Results: A 24 year-old man received his first epidural steroid injection for his chronic low back pain. Immediately after the procedure, he complained of bilateral frontal headache that was worse on standing and better in supine position. IV fluids, caffeine and blood patch did not completely alleviate the presumed PDPH. A computed tomography (CT) of head revealed pneumocephalus in the frontal and temporal part of the right lateral ventricle. In the view of unexpected pneumocephalus on CT head, a magnetic resonance imaging (MRI) of brain with contrast was pursued. MRI brain again showed pneumocephalus. However, MRI brain did not reveal any abnormal leptomeningeal enhancement or subdural hygroma to suggest the presence of intracranial hypotension. His headache was further improved with high-flow oxygen therapy. Repeat head CT at one week post-discharge showed resolution of pneumocephalus. Discussion / Conclusion: Here we report a rare case of coexisting PDPH and pneumocephalus after epidural steroid injection. The lack of MRI brain findings for intracranial hypotension was unexpected, but not surprising as studies have shown up to 20-30[percnt] of patients with intracranial hypotension would have a normal cranial MRI. Since orthostatic headache is not reliable to rule out pneumocephalus, especially in patient with coexisting PDPH, we believe early brain imaging might be indicated in patients with orthostatic headache that is refractory of conventional therapy. Disclosure: Dr. Limaye has nothing to disclose. Dr. Mahuwala has nothing to disclose. Dr. Lee has nothing to disclose.

Spinal Cord Hemorrhage

BACKGROUND AND PURPOSE Spinal cord hemorrhages are rare conditions that can be classified based on the primary location of bleeding into intramedullary (hematomyelia), subarachnoid hemorrhage (SAH), subdural hemorrhage, and epidural hemorrhage. We conducted a literature review to better understand the presenting symptoms, etiology, diagnosis, and treatment of spinal cord hemorrhages. METHODS We performed a literature search using PubMed with the key words spinal hemorrhage, hematomyelia, spinal subarachnoid hemorrhage, spinal subdural hematoma, and spinal epidural hematoma RESULTS: Most commonly, spinal hematomas present with acute onset of pain and myelopathy but a more insidious course also may occur. Spinal SAH may be especially difficult as it may cause cerebral symptoms. The etiologies vary based on the type (location). The most common causes are trauma, iatrogenic causes, vascular malformations, and bleeding diatheses. Management is often aimed toward rapid surgical decompression and correction of the underlying etiology if possible. Conservative management, including administration of large doses of corticosteroids, reversal of anticoagulation, and close monitoring, has been used as bridging for surgical procedure or as the mainstay of treatment for patients with mild or improving symptoms. CONCLUSIONS The variable and overlapping presentations of spinal cord hemorrhages make the diagnosis challenging. Maintaining high levels of clinical suspicion and utilizing magnetic resonance imaging may help in making the right diagnosis. Future studies should aim to create standardized outcome grading system and management guidelines for patients with spinal hemorrhage.

Intracranial Large and Medium Artery Atherosclerotic Disease and Stroke

BACKGROUND Intracranial atherosclerotic disease (ICAD) is one of the most common causes of stroke worldwide and is associated with a high risk of stroke recurrence. We sought to perform a literature review of the epidemiology, pathophysiology, and treatment options. METHODS A literature review on recent studies evaluating the epidemiology, risk factors, clinical presentation, and treatment was reviewed. ICAD is particularly common in Africa and Asia. RESULTS Although the medical management of ICAD has improved over the past decade, a subgroup of patients with ICAD remains at significantly high risk of stroke recurrence, and newer studies that aim at improving our understanding of ICAD and evaluating new treatment methods are currently under way. CONCLUSION ICAD remains a common cause of stroke worldwide; further studies evaluating treatment options to prevent stroke recurrence are urgently needed.

Diagnosis and Treatment of Primary Central Nervous System Angiitis

Purpose of reviewPrimary central nervous system angiitis (PCNSA) is a rare disease. Varying clinical pictures coupled with lack of sensitive and specific diagnostic tests lead to challenges in management of these patients. This unfortunately may lead to both under- or over-diagnosis and unnecessary treatment. It is important to recognize the different conditions that may mimic the clinical and radiologic presentation. We present a contemporary literature review that should update physicians who encounter this patient population.Recent findingsRecent additions to the literature in form of case reports and single-center series show that digital subtraction angiography was the most widely used test to diagnose PCNSA. It is also important to note that brain biopsy is still considered “gold standard” and should be pursued as it not only has information that establishes the diagnosis but also may help in ruling out the diagnosis from mimics. In around 39% of suspected cases, an alternate diagnosis was eventually confirmed highlighting the importance of a comprehensive work-up. For treatment, almost all the literature supports the use of glucocorticoids as the initial treatment and if the patient has a relapse or develops steroid toxicity then the second most commonly used agent was cyclophosphamide. There are increasing reports of benefits with other agents such as methotrexate, azathioprine, mycophenolate, infliximab, and etanercept.SummaryThe diagnosis and management of PCNSA continues to be a challenge. Formation of prospective patient registries with continued immunologic research for novel targets and immunomodulatory modalities may hold promise for future care of these patients.

Update in the Early Management and Reperfusion Strategies of Patients with Acute Ischemic Stroke

Acute ischemic stroke (AIS) remains a leading cause of death and long-term disability. The paradigms on prehospital care, reperfusion therapies, and postreperfusion management of patients with AIS continue to evolve. After the publication of pivotal clinical trials, endovascular thrombectomy has become part of the standard of care in selected cases of AIS since 2015. New stroke guidelines have been recently published, and the time window for mechanical thrombectomy has now been extended up to 24 hours. This review aims to provide a focused up-to-date review for the early management of adult patients with AIS and introduce the new upcoming areas of ongoing research.

Caution! Self-supplementation may be injurious to your health.

To the Editor, Copper is an essential trace element in key metalloenzymes that have an important role in the structure and function of the nervous system [1]. Copper deficiency is rare due to its ubiquitous distribution and low dietary requirements. It can result from gastrointestinal surgery, zinc excess, malabsorption syndromes and parenteral nutrition. Copper deficiency causes an ataxic myelopathy in ruminant animals but in 2001 a relationship to myelopathy in humans was described [1, 2]. Copper deficiency myelopathy can affect the pyramidal tracts and dorsal columns in the spinal cord mimicking subacute combined degeneration [1, 2]. Here, we present a case of a 66-year-old woman who had undergone gastric bypass surgery 32 years ago. She presented with a 1-year history of numbness in her hands and leg that progressed over months from her toes to her waist, and 6 months of progressive gait difficulty requiring her to use a walker for support. She had been taking parenteral vitamin B12 monthly for 2 years and zinc supplements (50 mg of zinc gluconate for 4 years and 25 mg of zinc in a multivitamin for 1 year). On neurologic examination, her cranial nerves were intact, motor testing showed 5/5 strength except for 4/5 in right first dorsal interosseous (FDI), 4-/5 left FDI, 4/5 hip flexors, knee flexors/extensors, and big toe extensors. Lower extremity tone was mildly spastic sensation was diminished to pin prick to the mid ankles, vibration sensation was absent to the knees bilaterally and proprioception was impaired in the bilateral big toes. Her left toe was extensor on plantar testing. She had mild dysmetria on finger nose finger and mild truncal titubation. Gait was wide based and ataxic. Laboratories at presentation included normal complete blood count, electrolytes, liver function test. vitamin B12 level (1161 pg/ml; normal 180–914 pg/ml), serum methylmalonic acid (0.2 lmol/L; normal 0.00–0.40 lmol/ L), vitamin B1, folic acid, HbA1c, serum protein immunoelectrophoresis and urine protein immunoelectrophoresis. Antinuclear antibody, SS-A, SS-B, anti-smithanti-ds DNA antibodies were negative and rheumatoid factor level was normal. Syphilis serology was negative. Her copper level was undetectable (\10 lg/dl; normal 80–155 lg/dL). Ceruloplasmin level was low (\3, normal 17–54 mg/dL). Zinc levels were normal (91 lg/dl; normal 60–120 lg/dL). Magnetic resonance imaging (MRI) revealed hyperintense T2 signal in the dorsal columns of the cervical and thoracic spine (Fig. 1a, b) with no evidence of compressive myelopathy. Nerve conduction studies with EMG revealed markedly slow sensory nerve conduction velocities and normal motor nerve conduction potentials suggesting a sensory demyelinating neuropathy. Diagnosis of myelopathy secondary to copper deficiency was made. Zinc supplements were stopped and she was started on intravenous cupric chloride (2 mg/day elemental copper) for 5 days. On day 6 copper levels had improved to 63 ug/dl and oral copper supplementation was started. On 3-month follow-up after hospital discharge, she had subjective and objective improvement in signs and symptoms, while repeat imaging studies were unchanged. & Kaustubh Limaye limayekaustubh@gmail.com

Spectrum of Cerebrovascular Disease in Patients with Multiple Myeloma Undergoing Chemotherapy—Results of a Case Control Study

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