Cerebral microbleeds in acute respiratory distress syndrome.

BACKGROUND: Cerebral microbleeds (CMB) have been observed in patients with critical illness. We sought to examine the frequency of CMB in patients with acute respiratory distress syndrome (ARDS) and association with neurologic complications including acute cerebral ischemia and seizures. METHODS: A retrospective review of patients with ARDS from January 2010 to October 2018 was performed. Patients with brain MRIs with susceptibility weighted imaging or gradient echo sequences were included. We compared neurologic complications and intensive care unit outcomes between patients with and without CMB. Cerebral small vessel disease (CSVD) was defined as the presence of CMB, lacunar infarcts, enlarged perivascular spaces, and white matter hyperintensities. RESULTS: Of 678 patients with ARDS, 61 met inclusion criteria. Median age was 54 years (IQR 42-63) and 28 were males. Of 12 (20%) with CMB, 10 had lobar CMB. Four patients had CMB in the corpus callosum, all involving the splenium. Neurologic complications were more common in those with CMB including acute cerebral ischemia (41.7% versus 10.2%, p=0.008) and seizures (33.3% versus 8.2%, p=0.021). ARDS rescue therapies were more commonly used in patients with CMB (p=0.005). There was no difference in hospital mortality (41.7% versus 34.7%, p=0.652). Patients with CMB did not have a higher CSVD score than those without CMB when accounting for the presence of CMB (median=1 versus 0, p=0.891). CONCLUSION: CMB were present in twenty percent of patients with ARDS who had MRI and were more commonly seen in patients requiring ARDS rescue therapies.

Cannabis Use and Stroke: Does a Risk Exist?

AIMS: Cannabis use has been reported as a risk factor for stroke. We systematically review the prevalence and outcomes of stroke in people with cannabis use. METHODS: We searched MEDLINE and 6 other databases from inception to January 2020 for studies on the relationship between cannabis use and stroke. We followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) recommendations. Two independent reviewers extracted the data. Study quality was assessed by the Newcastle-Ottawa Scale for cohort and case-control studies. RESULTS: Seventeen studies involving 3,185,560 people with cannabis use were included. Descriptive statistics demonstrated 18,676 (median 1.1%, interquartile range [IQR] 0.3%-1.3%) experienced stroke compared with 0.8% of those without use (Odds Ratio 1.17, 95% CI 1.10-1.25). Among people with cannabis use, median age was 26.2 years (IQR 25.2-34.3 years) and mostly male (median 57.8%). Of stroke subtypes, ischemic stroke was most prevalent (median 1.2%, IQR 0.4%-1.9%), followed by undefined stroke subtype (median 1.2%, IQR 1.1%-1.2%) and hemorrhagic stroke (median 0.3%, IQR 0.1%-0.6%). The majority of people with cannabis use who experienced stroke survived (median: 85.1%, IQR 83%-87.5%) and 64.0% of people experienced a good neurologic outcome, defined as modified Rankin Scale of 0 to 3. Few studies included outcomes of vasospasm or seizure. CONCLUSIONS: In people with cannabis use, the prevalence of ischemic stroke and hemorrhagic stroke was 1.2% and 0.3%, respectively, higher than the prevalence of people without use (0.8% and 0.2%). There is insufficient information on timing, exposure, duration, and dose-responsive relationship.

IV tPA given in the golden hour for emergent large vessel occlusion stroke improves recanalization rates and clinical outcomes.

BACKGROUND: Early thrombolysis for acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) is associated with better clinical outcome. This is thought to be due to greater tissue salvage with earlier recanalization. We explored whether ultra-early administration of intravenous tissue plasminogen activator (IV tPA) within 60 min (Golden Hour) of symptom onset for AIS due to ELVO is associated with a higher rate of recanalization. METHODS: We performed a retrospective analysis of recanalization rates and clinical outcomes in patients with AIS due to ELVO treated with IV tPA, comparing patients who received IV tPA within 60 min of stroke symptom onset with those treated beyond 60 min. RESULTS: Between January 2013 and December 2016, 158 patients with AIS due to ELVO were treated with IV tPA. Of these, 25 (15.8%) patients received IV tPA within 60 min of stroke symptom onset, while the remaining 133 (84.2%) patients received IV tPA beyond 60 min. The ultra-early treatment group was found to have a higher rate of complete recanalization (28.0% vs 6.8%, 95% CI 1.78-16.63), better chance of early neurological improvement (76.0% vs 50.4%, 95% CI 1.16-8.65), favorable clinical outcomes (mRS ≤ 2 or return to premorbid mRS) (65.0% vs 36.8%, 95% CI 1.42-9.34), and lower mortality (5% vs 31.1%, 95% CI 0.01-0.74) at 90-day follow-up compared to the later treatment group. CONCLUSION: Our data suggest that ultra-early administration of IV tPA significantly improves recanalization rates and clinical outcomes in patients with AIS due to ELVO.

Neurologic Injuries in Noncontact Sports.

Noncontact sports are associated with a variety of neurologic injuries. Concussion, vascular injury (arterial dissection), and spinal cord trauma may be less common in noncontact sports, but require special attention from the sports neurologist. Complex regional pain disorders, muscle injury from repetitive use, dystonia, heat exposure, and vascular disorders (patent foramen ovale), occur with similar frequency in noncontact and contact sports. Management of athletes with these conditions requires an understanding of the neurologic consequences of these disorders, the risk of injury with return to play, and consideration for the benefits of exercise in health restoration and disease prevention.

Acral gangrene as a presentation of non-uremic calciphylaxis.

We are describing a case of 55-year-old obese female with significant history of uncontrolled rheumatoid arthritis, who recently had decreased her immune-suppression medications. She presented with extensive acral gangrene involving multiple fingers and toes. Clinical picture and laboratory findings were suggestive of vasculitis; however, skin biopsy established diagnosis of calciphylaxis, in settings of normal kidney function. Patient was treated with sodium thiosulfate with gradual improvement in her skin lesions.