Transcarotid Arterial Revascularization of Symptomatic Internal Carotid Artery Disease: A Systematic Review and Study-Level Meta-Analysis.

BACKGROUND: Transcarotid artery revascularization (TCAR) is an interventional therapy for symptomatic internal carotid artery disease. Currently, the utilization of TCAR is contentious due to limited evidence. In this study, we evaluate the safety and efficacy of TCAR in patients with symptomatic internal carotid artery disease compared with carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: A systematic review was conducted, spanning from January 2000 to February 2023, encompassing studies that used TCAR for the treatment of symptomatic internal carotid artery disease. The primary outcomes included a 30-day stroke or transient ischemic attack, myocardial infarction, and mortality. Secondary outcomes comprised cranial nerve injury and major bleeding. Pooled odds ratios (ORs) for each outcome were calculated to compare TCAR with CEA and CAS. Furthermore, subgroup analyses were performed based on age and degree of stenosis. In addition, a sensitivity analysis was conducted by excluding the vascular quality initiative registry population. RESULTS: A total of 7 studies involving 24 246 patients were analyzed. Within this patient cohort, 4771 individuals underwent TCAR, 12 350 underwent CEA, and 7125 patients underwent CAS. Compared with CAS, TCAR was associated with a similar rate of stroke or transient ischemic attack (OR, 0.77 [95% CI, 0.33-1.82]) and myocardial infarction (OR, 1.29 [95% CI, 0.83-2.01]) but lower mortality (OR, 0.42 [95% CI, 0.22-0.81]). Compared with CEA, TCAR was associated with a higher rate of stroke or transient ischemic attack (OR, 1.26 [95% CI, 1.03-1.54]) but similar rates of myocardial infarction (OR, 0.9 [95% CI, 0.64-1.38]) and mortality (OR, 1.35 [95% CI, 0.87-2.10]). CONCLUSIONS: Although CEA has traditionally been considered superior to stenting for symptomatic carotid stenosis, TCAR may have some advantages over CAS. Prospective randomized trials comparing the 3 modalities are needed.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis.

BACKGROUND: Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use. METHODS AND RESULTS: A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration. CONCLUSIONS: Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.

In-hospital outcomes and recurrence of stroke during pregnancy and puerperium.

BACKGROUND: There are limited data regarding the best management and outcomes of acute stroke during pregnancy and the puerperium. METHODS: Pregnancy-related hospitalizations with age > 18 years were identified from the Nationwide Readmissions Database 2016-2018. The study cohort consisted of all patients with acute stroke and a 5% random sample of the remaining non-stroke hospitalizations. Logistic regression and survival analyses were used to compare the in-hospital outcomes and readmissions in patients with and without acute stroke. RESULTS: There were 11,829,044 pregnancy-related hospitalizations, of which 4057 had acute stroke. The mean ± SD age of the study cohort was 29.0 ± 5.7 years. Among patients with acute ischemic stroke, 60 (3.7%) patients received intravenous thrombolysis and 112 (6.8%) patients underwent endovascular thrombectomy. Among patients with intracranial hemorrhage, 205 (10.5%) patients underwent ventriculostomy and 18 (0.9%) patients underwent decompressive craniotomy. Patients with stroke had longer length of stay (mean: 10.7 vs 2.7 days), higher in-hospital mortality (4.6% vs 0.0001%) and were less likely to discharge home (73.0% vs 98.6%). Non-elective readmission within 90 days of discharge occurred in 14.8% of patients with stroke versus in 3.9% of patients without stroke. Readmissions due to cerebrovascular events occurred in 2.3% of patients with stroke versus in 0.007% of patients without stroke within 1 year of discharge, with mean ± SD time to readmission 66.2 ± 78.0 days. CONCLUSION: Stroke is a serious complication of pregnancy, associated with high morbidity and mortality. Recurrence of stroke occurs in a small proportion of patients, and the risk is highest during the initial 3 months.

Endovascular coiling versus neurosurgical clipping for treatment of ruptured and unruptured intracranial aneurysms during pregnancy and postpartum period.

BACKGROUND: Selection of appropriate surgical strategy for the treatment of intracranial aneurysms (IA) during pregnancy requires careful consideration of the potential risks to the mother and fetus. However, limited data guide treatment decisions in these patients. We compared the safety profiles of endovascular coiling (EC) and neurosurgical clipping (NC) performed for the treatment of ruptured and unruptured IA during pregnancy and the postpartum period. METHODS: Pregnancy-related or postpartum hospitalizations undergoing surgical intervention for IA were identified from the Nationwide Readmissions Database 2016-2018. Safety outcomes included periprocedural complications, in-hospital mortality, discharge disposition, and 30-day non-elective readmissions. RESULTS: There were 348 pregnancy-related or postpartum hospitalizations that met the study inclusion criteria (mean±SD age 31.8±5.9 years). Among 168 patients treated for ruptured aneurysms, 115 (68.5%) underwent EC and 53 (31.5%) underwent NC; whereas among 180 patients treated for unruptured aneurysms, 140 (77.8%) underwent EC and 40 (22.2%) underwent NC. There were no statistically significant differences in the baseline characteristics between patients undergoing EC versus NC for either ruptured or unruptured aneurysm groups. The outcomes were statistically comparable between EC and NC for both ruptured and unruptured IA, except for a lower incidence of ischemic stroke in patients undergoing EC for ruptured aneurysms (OR 0.12, 95% CI 0.02 to 0.84). CONCLUSIONS: Most pregnant and postpartum patients are treated with EC for both ruptured and unruptured IA. For treatment of ruptured IA, EC is independently associated with a lower risk of perioperative ischemic stroke, but other in-hospital complications and mortality are comparable between EC and NC.

Early Readmissions After Hospitalization for Posterior Reversible Encephalopathy Syndrome.

OBJECTIVE: To evaluate the frequency, etiologies, and risk factors for 90-day readmissions following hospitalization for PRES. METHODS: Data were obtained from the Nationwide Readmissions Database 2016-2018. Patients with primary diagnosis of PRES, survival to discharge, and known discharge disposition were included. Primary outcome was non-elective readmission within 90 days of discharge. Survival analysis was performed, and independent predictors of readmission were analyzed using multivariable Cox proportional hazards regression. RESULTS: Based on the study inclusion criteria, 6,155 eligible patients were included (mean±SD age: 55.9±17.3 years, female: 71.0%). Non-elective readmission within 90 days of discharge occurred for 1,922 (31.2%) patients. Of these, 617 readmissions were due to PRES-related or neurological etiologies and the remaining 1305 readmissions were due to non-neurological conditions. In multivariable analysis, age was inversely associated with risk of readmission [hazards ratio (HR): 0.92 for every 10 years increase in age, 95% confidence interval (CI): 0.88-0.97]. Patients with diabetes (HR: 1.21, 95% CI: 1.04-1.42), systemic lupus erythematosus (HR: 1.42, 95% CI: 1.03-1.96), acute kidney injury (HR: 1.28, 95% CI: 1.11-1.47) and higher Charlson comorbidity index score (HR: 1.09, 95% CI: 1.06-1.13) were more likely to be readmitted. Further, patients admitted at large bed size hospitals (HR: 1.19, 95% CI: 1.03-1.39), those with longer length of stay (HR: 1.01, 95% CI: 1.00-1.02) and those not discharged to home (HR: 1.33, 95% CI: 1.14-1.55) during the index hospitalization were also at a higher risk for readmission. CONCLUSION: Nearly one-third of patients hospitalized due to PRES are readmitted within 90 days of discharge and about one-third of these readmissions are due to PRES-related or neurological etiologies. Younger age, a higher comorbidity burden, longer length of hospital stay, and discharge disposition other than to home are independently associated with the risk of readmission.

Effects of the Menstrual Cycle on Neurological Disorders.

PURPOSE OF REVIEW: The menstrual cycle involves recurrent fluctuations in hormone levels and temperature via neuroendocrine feedback loops. This paper reviews the impact of the menstrual cycle on several common neurological conditions, including migraine, seizures, multiple sclerosis, stroke, and Parkinson's disease. RECENT FINDINGS: The ovarian steroid hormones, estrogen and progesterone, have protean effects on central nervous system functioning that can impact the likelihood, severity, and presentation of many neurological diseases. Hormonal therapies have been explored as a potential treatment for many neurological diseases with varying degrees of evidence and success. Neurological conditions also impact women's reproductive health, and the cessation of ovarian function with menopause may also alter the course of neurological diseases. Medication selection must consider hormonal effects on metabolism and the potential for adverse drug reactions related to menstruation, fertility, and pregnancy outcomes. Novel medications with selective affinity for hormonal receptors are desirable. Neurologists and gynecologists must collaborate to provide optimal care for women with neurological disorders.

Inpatient Neurology Consultations During the Onset of the SARS-CoV-2 New York City Pandemic: A Single Center Case Series.

Objective: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily causes respiratory illness. However, neurological sequelae from novel coronavirus disease 2019 (COVID-19) can occur. Patients with neurological conditions may be at higher risk of developing worsening of their underlying problem. Here we document our initial experiences as neurologic consultants at a single center quaternary hospital at the epicenter of the COVID-19 pandemic. Methods: This was a retrospective case series of adult patients diagnosed with SARS-CoV-2 who required neurological evaluation in the form of a consultation or primary neurological care from March 13, 2020 to April 1, 2020. Results: Thirty-three patients (ages 17-88 years) with COVID-19 infection who required neurological or admission to a primary neurology team were included in this study. The encountered neurological problems associated with SARS-CoV-2 infection were encephalopathy (12 patients, 36.4%), seizure (9 patients, 27.2%), stroke (5 patients, 15.2%), recrudescence of prior neurological disease symptoms (4 patients, 12.1%), and neuromuscular (3 patients, 9.1%). The majority of patients who required evaluation by neurology had elevated inflammatory markers. Twenty-one (63.6%) patients were discharged from the hospital and 12 (36.4%) died from COVID-19 related complications. Conclusion: This small case series of our initial encounters with COVID-19 infection describes a range of neurological complications which are similar to presentations seen with other critical illnesses. COVID-19 infection did not change the overall management of neurological problems.

Ischemic stroke and cerebral venous sinus thrombosis in pregnancy.

Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.

Current and future uses of probiotics.

The relationship between host and gut microbiota has been the topic of research in recent decades, with particular emphasis on various species of bacteria and their distinct role in health promotion. Early promising research led to the new term probiotic, coined to describe these beneficial bacteria. This early research has laid the foundation for various proposed mechanisms of probiotic effects on health. This article describes current areas of established probiotic use and introduces areas of current investigation, including psychobiotics, which may help patients suffering from psychiatric illness.