Rituximab for prevention of strokes in cerebral rheumatoid vasculitis.

Rheumatoid arthritis (RA) is an autoimmune disorder which manifests as inflammation of the synovial joints alongside extra-articular involvement. Uncommonly, patients may develop vasculitis of small and medium-sized blood vessels, formally diagnosed as systemic rheumatoid vasculitis (SRV). In particularly rare cases, patients may develop a subtype of SRV known as cerebral rheumatoid vasculitis (CRV) which manifests in patients as stroke. To date, no formal recommendations or guidelines have been established for treatment and prevention of CRV-induced stroke besides experiential therapy with various immunomodulators. Here, we describe the utility of Rituximab in addition to steroids for prevention of stroke in our patient with evidence of multiple CRV-induced strokes with excellent recovery of post-stroke symptoms and remission of new onset cerebral vasculitis processes.

Tales of a department: how the COVID-19 pandemic transformed Detroit's Henry Ford Hospital, Department of Neurology-part I: the surge.

The COVID-19 pandemic has reshaped the way healthcare systems operate around the world. The major hurdles faced have been availability of personal protective equipment, intensive care unit beds, ventilators, treatments and medical personnel. Detroit, Michigan has been an epidemic 'hotspot' in the USA with Wayne County among the hardest hit counties in the nation. The Department of Neurology at Henry Ford Hospital, in the heart of Detroit, has responded effectively to the pandemic by altering many aspects of its operations. The rapid engagement of the department and enhanced utilisation of teleneurology were two of the pivotal elements in the successful response to the pandemic. In this review, we describe the transformation our department has undergone, as it relates to its infrastructure redesigning, coverage restructuring, redeployment strategies, medical education adaptations and novel research initiatives.

What to Look for on Post-stroke Neuroimaging.

The most feared complication after acute ischemic stroke is symptomatic or asymptomatic hemorrhagic conversion. Neuroimaging and clinical criteria are used to predict development of hemorrhage. Seizures after acute ischemic stroke or stroke-like symptoms from seizures are not common but may lead to confusion in the peristroke period, especially if seizures are repetitive or evolve into status epilepticus, which could affect neuroimaging findings. Malignant infarction develops when cytotoxic edema is large enough to lead to herniation and death. Post-stroke neuroimaging prognosticators have been described and should be assessed early so that appropriate treatment is offered before herniation leads to additional tissue injury.

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

BACKGROUND: The 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. METHODS: We 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. RESULTS: We 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). CONCLUSION: MCOT 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.

Creating accountable care for carotid angioplasty and stenting: A multidisciplinary carotid revascularization board.

BACKGROUND: We tested the feasibility of a mandated multidisciplinary carotid revascularization board (MDCB) to review, approve and monitor all carotid artery and stenting (CAS) procedures and outcomes at our institution. METHODS: The board was composed of vascular surgeons, cardiologists, interventional neuroradiologists, neurosurgeons, and neurologists, who met weekly to facilitate an evidence-based, consensus recommendation to ensure appropriate CAS referral. RESULTS: The board successfully reviewed and continues to review and approve all CAS procedures at our center. Of the 69 patients considered high risk for standard surgical treatment, 42 patients were symptomatic and 27 patients were asymptomatic. Their mean age was 70.5-year-old and the median degree of stenosis was 79%. In the 74 procedures, periprocedural complications occurred at the following rates: 2.7% death, 2.7% major stroke, 2.7% minor stroke, and 2.7% myocardial infarction (MI) within 30 days of the procedure. At 1 year the primary endpoints of ipsilateral stroke and neurovascular-related death were observed in 8.1% and 2.7% of the patients, respectively. At mean follow-up of 21 months, 18.8% of the patients (13/69) had died (including all causes), and 14.5% (10/69) experienced stroke (including nontarget strokes). Target vessel revascularization was needed in 2.9% patients. CONCLUSIONS: A mandated multidisciplinary carotid revascularization board MDCB is feasible and potentially advantageous in real clinical practice. It establishes a model for accountable care by providing a mechanism for institutional oversight, credentialing operators, quality review, standardizing care, cost containment and eliminating the "subspecialty silo mentality."

Development of a scoring system for atrial fibrillation in acute stroke and transient ischemic attack patients: the LADS scoring system.

INTRODUCTION: Detection of atrial fibrillation in patients presenting with ischemic stroke or transient ischemic attack (TIA) is important for the prevention of future events. We sought to develop a scoring system that would identify those patients most likely to have atrial fibrillation. METHODS: Records from an inpatient stroke and TIA database and echocardiographic data were reviewed. Consecutive acute stroke and TIA patients over the age of 18 who were admitted during a two-year period were studied. Univariate and multivariable analyses were performed to identify variables associated with atrial fibrillation. Logistic regression analyses were used to develop a scoring system for atrial fibrillation. RESULTS: 953 patient charts were reviewed; 145 patients (15%) had atrial fibrillation. In univariate and multivariate analyses, variables that were significantly associated with atrial fibrillation included left atrial diameter, age, and diagnosis of stroke. A history of smoking showed an inverse association. A 6-point scoring system based on these variables (with the acronym of LADS) was developed. A score of 4 or greater was associated with a sensitivity of 85.5% and a specificity of 53.1%. Approximately 47% of stroke and TIA patients would be excluded from further investigation using this score. CONCLUSIONS: We describe a system of scoring that identifies acute stroke and TIA patients with a greater chance of having atrial fibrillation. An inverse relationship with smoking was found. Further prospective studies are required to determine the clinical utility and cost-effectiveness of this scoring system in clinical practice and to investigate the inverse relationship between smoking and atrial fibrillation in this population.

Moyamoya syndrome associated with Graves' disease: a case report and review of the literature.

We report a patient and critically review the literature in order to define the demographic, clinical, neuroradiologic, and treatment features of moyamoya syndrome (MMS) in the setting of Graves' disease (GD). We performed a comprehensive English language Medline search using the keywords "moyamoya," "Graves' disease," and "thyrotoxicosis." We included all patients with angiographic findings consistent with MMS. A 23-year-old woman with active GD presented with intermittent confusion and right arm paresis. Brain magnetic resonance imaging revealed acute left and chronic bilateral hemispheric infarcts. Cerebral angiography revealed multivessel intracranial occlusive disease. Initial treatment with plasmapheresis plus aspirin stabilized the patient's neurologic deficits. Antithyroid treatment plus subsequent surgical encephalomyosynangiosis resulted in prolonged neurologic stability. We studied 30 patients (27 women [90%], 23 of Asian descent [77%]), with a mean age of 29 ± 11.6 years. Hemiparesis (n = 12; 40%) was the leading clinical sign, and ischemic infarction was the most frequent neuroimaging finding (n = 26; 87%). Treatment regimens included antithyroid medications alone (n = 5; 17%), antithyroid plus antiplatelet agents (n = 9; 30%), neurosurgical revascularization after antithyroid medication (n = 11; 37%), and plasmapheresis in the acute thyrotoxic state (n = 2; 7%). Most patients had good short-to-medium term outcome (n = 14; 78% of reported outcome). Plasmapheresis-treated patients achieved neurologic stabilization and had good outcomes. MMS, an infrequent complication of GD, typically affects young women. Our findings indicate that plasmapheresis can stabilize the neurologic picture in the acute phase, and that antithyroid and antiplatelet therapy, combined with revascularization surgery, may improve long-term outcomes. Further work is needed to establish an optimal treatment strategy.

Periictal diffusion abnormalities of the thalamus in partial status epilepticus.

PURPOSE: To identify and describe thalamic dysfunction in patients with temporal as well as extratemporal status epilepticus (SE) and to also analyze the specific clinical, radiological, and electroencephalography (EEG) characteristics of patients with acute thalamic involvement. METHODS: We retrospectively identified patients who presented with clinical and electrographic evidence of partial SE and had thalamic abnormalities on diffusion-weighted imaging (DWI) within 5 days of documentation of lateralized epileptiform discharges (group 1). The spatial and temporal characteristics of the periodic lateralized epileptiform discharges (PLEDs) and the recorded electrographic seizures were analyzed and correlated with magnetic resonance imaging (MRI)-DWI hyperintense lesions. The findings of group 1 patients were compared with those of patients with partial SE without thalamic abnormalities on DWI (group 2). RESULTS: The two groups were similar with regard to clinical presentation and morphology of epileptiform discharges. Group 1 patients had thalamic hyperintense lesions on DWI that appeared in the region of the pulvinar nucleus, ipsilateral to the epileptiform activity. Statistically significant relationship was noted between the presence of thalamic lesions and ipsilateral cortical laminar involvement (p = 0.039) as well as seizure origin in the posterior quadrants (p = 0.038). A trend towards PLEDs originating in the posterior quadrants was also noted (p = 0.077). DISCUSSION: Thalamic DWI hyperintense lesions may be observed after prolonged partial SE and are likely the result of excessive activity in thalamic nuclei having reciprocal connections with the involved cortex. The thalamus likely participates in the evolution and propagation of partial seizures in SE.