Thrombolytic Therapy for Central Retinal Artery Occlusion in an Academic Multi-Site Stroke Centre.

Central retinal artery occlusion (CRAO) is a subtype of acute ischaemic stroke leading to severe visual loss. A recent American Heart Association scientific statement proposed time-windows for thrombolysis in CRAO similar to acute ischaemic cerebral strokes. We aimed to review our academic multi-site stroke centre experience with intravenous (IVT) and intra-arterial thrombolysis (IAT) in CRAO between 1997 and 2022. Demographic, clinical characteristics, thrombolysis timeline, concurrent therapies, complications, and 3-month follow-up visual acuity (VA) were collected. The thrombolysed cohort follow-up VA was compared with an age, gender and baseline VA matched cohort of CRAO patients that received conservative therapies. Thrombolytic therapy was administered to 3.55% (n = 20) of CRAO admissions; 13 IVT (mean age 68, 61.5% male, 12 alteplase and 1 tenecteplase, all embolic aetiology, 1 CRAO mimic) and 7 IAT (mean age 55, 85.7% male, 3 post-operative and 3 embolic). Additional conservative CRAO-targeting therapies was received by 60%. The median time from onset of visual loss to IVT was 158 minutes (range 67-260). Improvement by at least two Snellen lines was achieved by 25% with 12.5% improving to 20/100 or better. Intracranial haemorrhage post IVT occurred in 1/13 (7.6%). The median time from onset of visual loss to IAT was 335 minutes. Improvement by at least two Snellen lines was achieved by 42%. No difference in 3-month VA was noted between patients that received thrombolysis, either alone (n = 8) or combined with other therapies, and those that received conservative therapies. Our results suggest that the management of acute CRAO remains heterogeneous. The lack of obvious benefit of thrombolysis in our small series supports the need for randomizsd clinical trials comparing thrombolysis to placebo to guide hyperacute CRAO management.

Blood pressure elevation in erenumab-treated patients with migraine: A retrospective real-world experience.

BACKGROUND: Erenumab is a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) receptor and is approved for the preventative treatment of migraine in adults. CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension. While there has not been evidence of hypertension in preclinical models or clinical trials, post-marketing data suggest erenumab may be associated with hypertension. This led to a warning in the United States Food and Drug Administration prescribing information for erenumab. OBJECTIVE: To determine the frequency of worsening blood pressure (BP) after initiation of erenumab in patients with migraine and how this is associated with hypertension. METHODS: This is an observational retrospective cohort study evaluating patients at a tertiary headache or neurology department. Systolic and diastolic BPs were compared between the initial visit prior to initiation of erenumab, and follow-up visit while on erenumab. Worsening BP was defined as moving from a lower stage to a higher stage of BP, as defined by the American Heart Association. Serious adverse vascular events were also recorded. RESULTS: A total of 335 patients were included in the final analysis (mean [SD] age of 45.7 [14.40] years, 83.9% [281/335] female). At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The median (interquartile range) time to follow-up appointment from initial appointment was 20.5 (13.3-35.3) weeks. The mean (SD) BP at baseline was systolic 124.7 (15) mmHg and diastolic 77 (11) mmHg, and at follow-up was systolic 124.0 (15) mmHg and diastolic 77.8 (9) mmHg. Overall, 23.3% (78/335) of all patients had worsening BP, whereas 13/225 (3.9%) patients had improvement in their BP. Patients with atrial fibrillation were more likely to develop worsening BP (odds ratio, 4.9, 95% confidence interval 1.12-21.4; p = 0.035). There was no association between worsening BP and pre-existing hypertension, sex, body mass index, or age. One patient had non-ST elevation myocardial infarction attributed to a hypertensive emergency while on erenumab. CONCLUSION: We found that 23.3% of patients initiated on erenumab may have developed worsening BP, suggesting the need for BP monitoring in patients initiated on erenumab.

Can Pyridoxine Successfully Reduce Behavioral Side Effects from Levetiracetam?: A Critically Appraised Topic.

BACKGROUND: Levetiracetam is a commonly used anti-seizure medication, with the development of neuropsychiatric symptoms being the most common side effect. Preliminary literature describes the improvement of these symptoms with pyridoxine, mostly within the pediatric population. However, randomized control trial data investigating this relationship is sparse. OBJECTIVE: The objective of this study was to critically assess evidence regarding the role of pyridoxine in the treatment of neuropsychiatric symptoms from levetiracetam. METHODS: The objective was addressed through the development of a structured, critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, medical librarians, clinical epidemiologists, and content experts in the field of epilepsy. RESULTS: A randomized, placebo-controlled clinical trial was selected for critical appraisal. This trial compared pyridoxine versus placebo for the treatment of neuropsychiatric symptoms from levetiracetam in a pediatric population and included 105 patients (46/105 received pyridoxine, 59/105 received placebo). It found that both groups had a significant reduction in behavioral symptoms at the 2-,4-and 6-week time points ( P <0.05). However, the authors noted that the pyridoxine group had almost double the relative reduction when compared with the placebo group at all time points: 1.9 at 2 weeks, 2.0 at 4 weeks, and 1.8 at 6 weeks ( P =0.001). CONCLUSIONS: This study suggests that pyridoxine for the treatment of levetiracetam-induced behavioral side effects may result in modest improvement, although many limitations prevent conclusive results. There remains a need for a double-blinded, randomized control trial in both the adult and pediatric populations.

Migraine and the Gender Divide.

Migraine is a global neurologic disease that is highly prevalent, especially in women. Studies have observed a predisposition for the development of migraine in women, although the mechanisms involved have yet to be fully elucidated. This review aimed to summarize the recent evidence regarding the epidemiology, pathophysiology, and treatment of migraine and highlight key sex differences. We also identify gaps in care for both women and men living with migraine and discuss the presence of migraine-related stigma and how this may impact the efficacy of clinical care.

Magnetic Resonance Imaging Features of GABA-A Receptor Antibody-Mediated Encephalitis.

This case report describes a patient with status epilepticus and neuroimaging features of fleeting T2 fluid-attenuated inversion recovery hyperintense lesions on magnetic resonance imaging.

The Addition of Radiofrequency Tumor Ablation to Kyphoplasty May Reduce the Rate of Local Recurrence in Spinal Metastases Secondary to Breast Cancer.

BACKGROUND: Approximately 10% of all cancer patients develop spinal metastases. When a symptomatic compression fracture occurs without associated deformity or neurologic deficit, it can be treated with kyphoplasty with or without radiofrequency ablation (RFA). Treatment with kyphoplasty is well established but does not address the underlying oncologic disease. METHODS: Retrospective medical chart analysis of breast cancer patients (n = 23) with metastatic spinal fractures (n = 50 vertebral levels) who underwent RFA and kyphoplasty was undertaken. Key variables of interest included: fracture location, pain levels, and local recurrence. Local recurrence data were compared to published rates of recurrence in breast cancer-related metastatic spinal fractures treated with vertebroplasty or kyphoplasty alone. Data were analyzed using χ2 and t test statistical analyses. RESULTS: The mean preoperative pain level for this cohort was 6.9 on a 10-point visual analogue scale. Significant reductions in pain levels were observed postoperatively, at discharge (3.5; P < 0.05), at 1-month follow-up (2.8; P < 0.05), at 3-month follow-up (1.1; P < 0.05), and at 6-month follow-up (0.7 P < 0.05). Compared with published data of breast cancer patients with metastatic spinal fractures treated with vertebroplasty or kyphoplasty alone, the addition of RFA resulted in reduced local tumor recurrence (2% vs. 14%; P < 0.05). Average length of follow-up was 39 months. CONCLUSIONS: The results suggest that the addition of RFA to kyphoplasty may reduce local tumor recurrence while providing similar pain relief benefits. The extrapolation of this added benefit to metastases from other primary cancers should be examined in future studies.

National and State Level Opioid-Restricting Legislation in Total Joint Arthroplasty: A Systematic Review.

BACKGROUND: The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several years, there has been a growing interest and public effort toward reducing opioid use in total joint arthroplasty (TJA) in response to the opioid epidemic in the United States. We aim to review opioid-limiting practices, policies, and legislations that are implemented at the state level and nationally that are relevant to TJA, as well as evaluate studies that measure the efficacy of these policies in the management of patients undergoing TJA. METHODS: Two independent reviewers conducted a systematic review of national and state level opioid-limiting policies implemented in the United States and their effects on opioid prescription, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). RESULTS: We identified 3 national bills and 9 policies set forth by national organizations that imposed limits on opioid prescription. Opioid-reducing legislation was also identified in 24 states, with the majority specifying a 7-day limit on initial opioid prescription for acute pain management. Six research studies evaluating the impact of opioid-restricting policies on postoperative opioid prescription for TJA patients were found. Three studies assessed legislation at the state level while the others were institution-based guidelines. Overall, these studies demonstrated a significant decrease in mean morphine milligram equivalents of initial opioid prescription after implementing the policies. CONCLUSION: Recent opioid-restricting legislation is effective in decreasing postoperative opioid prescriptions following TJA.

Collapsing FSGS with Concurrent Class 2 and 3 Lupus Nephritis: A Case Report and Review of the Literature.

Lupus nephritis (LN) and the collapsing variant of focal segmental glomerulosclerosis (cFSGS) are separate histologic diagnoses that are generally thought to have separate etiologies. We describe the presentation of a 20-year-old African American female with advanced renal failure (creatinine 7.16 mg/dL), nephrotic-range proteinuria, and a 30-pound weight loss. Renal biopsy demonstrated class 2 and 3 LN as well as cFSGS. A review of the current literature demonstrates that the dual diagnosis of LN and cFSGS may not be as rare as previously understood. Whether the presence of one of these pathophysiologic processes predisposes a patient to the development of the other, or whether genetic variation increases the risk for development of both conditions, remains unclear. Currently there is no standard therapy to manage these patients, and overall renal prognosis is poor.

Industry-Sponsored Research Payments in Neurosurgery-Analysis of the Open Payments Database From 2014 to 2018.

BACKGROUND: The Open Payments Database (OPD) started in 2013 to combat financial conflicts of interest between physicians and medical industry. OBJECTIVE: To evaluate the first 5 yr of the OPD regarding industry-sponsored research funding (ISRF) in neurosurgery. METHODS: The Open Payments Research Payments dataset was examined from 2014 to 2018 for payments where the clinical primary investigator identified their specialty as neurosurgery. RESULTS: Between 2014 and 2018, a $106.77 million in ISRF was made to 731 neurosurgeons. Fewer than 11% of neurosurgeons received ISRF yearly. The average received $140 000 in total but the median received $30,000. This was because the highest paid neurosurgeon received $3.56 million. A greater proportion ISRF was made to neurosurgeons affiliated with teaching institutions when compared to other specialties (26.74% vs 20.89%, P = .0021). The proportion of the total value of ISRF distributed to neurosurgery declined from 0.43% of payments to all specialties in 2014 to 0.37% in 2018 (P < .001), but no steady decline was observed from year to year. CONCLUSION: ISRF to neurosurgeons comprises a small percentage of research payments made to medical research by industry sponsors. Although a greater percentage of payments are made to neurosurgeons in teaching institutions compared to other specialties, the majority is given to neurosurgeons not affiliated with a teaching institution. A significant percentage of ISRF is given to a small percentage of neurosurgeons. There may be opportunities for more neurosurgeons to engage in industry-sponsored research to advance our field as long as full and complete disclosures can always be made.

Symptomatic neurocutaneous melanosis: mild clinical onset in a teenager.

Neurocutaneous melanosis (NCM) is a rare disorder characterised by giant or multiple melanocytic nevi and meningeal melanosis or melanoma. Onset of neurological symptoms is typically in children younger than 2 years and can be rapidly fatal. We present the case of a 13-year-old adopted girl presenting with numerous congenital melanocytic nevi and a seizure. She had no significant previous neurological history. Electroencephalogram showed epileptiform discharges over the right frontal region. MRI of the brain showed T1 hyperintensity in the bilateral amygdala and anterior temporal lobes with corresponding hyperintensity on T2 and fluid attenuated inversion recovery. There was no hydrocephalus. Along with the history of nevi, these imaging findings were concerning for NCM. The patient is being managed with levetiracetam and trametinib and shows no further neurological decline at 1-year follow-up, providing prognostic hope in this case of NCM.

Atypical Presentation of Periprosthetic Joint Infection After Total Knee Arthroplasty due to Parvimonas micra.

There is limited literature reporting the oral pathogen Parvimonas micra as the causative organism of periprosthetic joint infection. Previous reports demonstrate septic arthritis in native or prosthetic joints due to P. micra in elderly or immunocompromised patients associated with tooth abscess and periodontal disease. Our case report is unique because it describes a healthy individual with recurrent gingivitis developing periprosthetic joint infection after total knee arthroplasty as the result of isolated P. micra. Her clinical symptom presented early and manifested as progressive stiffness only. Timely aspiration resulted in early diagnosis, but the patient still underwent 2-stage revision with a more constrained implant. To prevent the risk of infection by oral pathogens such as P. micra, dental history should be thoroughly investigated, and any lingering periodontal infection should be addressed before any arthroplasty operation.

Emergency Center Curbside Screening During the COVID-19 Pandemic: Retrospective Cohort Study.

BACKGROUND: Coronavirus disease (COVID-19) is a global pandemic that has placed a significant burden on health care systems in the United States. Michigan has been one of the top states affected by COVID-19. OBJECTIVE: We describe the emergency center curbside testing procedure implemented at Beaumont Hospital, a large hospital in Royal Oak, MI, and aim to evaluate its safety and efficiency. METHODS: Anticipating a surge in patients requiring testing, Beaumont Health implemented curbside testing, operated by a multidisciplinary team of health care workers, including physicians, advanced practice providers, residents, nurses, technicians, and registration staff. We report on the following outcomes over a period of 26 days (March 12, 2020, to April 6, 2020): time to medical decision, time spent documenting electronic medical records, overall screening time, and emergency center return evaluations. RESULTS: In total, 2782 patients received curbside services. A nasopharyngeal swab was performed on 1176 patients (41%), out of whom 348 (29.6%) tested positive. The median time for the entire process (from registration to discharge) was 28 minutes (IQR 17-44). The median time to final medical decision was 15 minutes (IQR 8-27). The median time from medical decision to discharge was 9 minutes (IQR 5-16). Only 257 patients (9.2%) returned to the emergency center for an evaluation within 7 or more days, of whom 64 were admitted to the hospital, 11 remained admitted, and 4 expired. CONCLUSIONS: Our curbside testing model encourages the incorporation of this model at other high-volume facilities during an infectious disease pandemic.