Transient Bilateral Ophthalmoplegia: A Case of a Forgotten Anesthetic Medication Effect.

A 58-year-old woman was found to have bilateral ptosis and downward gaze deviation immediately after elective shoulder surgery with general anesthesia and supraclavicular nerve block. A code stroke was activated due to concern for the neurologic process, but neuroimaging did not reveal acute changes or vascular abnormality. Her symptoms gradually resolved in the following hours with supportive care and were ultimately deemed to be related to anesthetic and transdermal scopolamine exposures layered upon her underlying comorbidities. Transient bilateral ophthalmoplegia after general anesthetics has been previously described; drug effect should be considered in the differential of this alarming presentation, which can mimic acute stroke and/or Horner syndrome.

Association of Patterns of Mild Traumatic Brain Injury with Neurologic Deterioration: Experience at a Level I Trauma Center.

INTRODUCTION: There are about 2.5 million emergency room visits for traumatic brain injury (TBI) every year and 75%-95% of all TBI patients have mild TBI. Previous studies have suggested that a large proportion of mild TBI patients can be treated in a non-aggressive manner, but they have not differentiated mild TBI as per radiological patterns to help in the selection of these patients. Our study aimed to identify different patterns of mild TBI to determine if certain injuries make patients more prone to neurologic worsening than others, and thus require more intensive monitoring. We also studied the factors associated with neurologic deterioration. METHODS: We conducted a retrospective study using an institutional trauma database to identify TBI patients between the years of 2015 and 2016 with admission Glasgow Coma Score (GCS) of 13 to 15, through chart review by the investigators. Radiological and neurological worsening was determined through computed tomography (CT) scan results, GCS scores, and the requirement for neurosurgical intervention. We identified the prevalence of demographic characteristics, radiological patterns, and risk factors. We studied neurologic deterioration (decline in GCS to less than 13 at 48 hours or earlier after admission) and surgical intervention among patients with different radiological patterns of TBI. We further studied the cohort of isolated subdural hematoma (SDH) patients requiring surgery to evaluate the associated risk factors. RESULTS: Out of 374 patients with mild TBI (mean age was 63 years), 59% were male, 77% were Caucasian, the median GCS was 15, majority of patients had isolated SDH (45%), and mixed pattern of hemorrhage (39%); the use of antiplatelet (33%) was the most commonly identified risk factors. Overall 7% of patients were found to have neurologic deterioration (GCS to less than 13) and 9% required surgical intervention at 48 hours or earlier after admission. The most common pattern of TBI requiring surgical intervention was isolated SDH (85%). Among the cohort of patients with isolated SDH, 17% required surgical intervention and 69% of those isolated SDH patients requiring surgery had neurologic deterioration. The most common risk factor in isolated SDH patients requiring surgery was antiplatelet use (34%), anticoagulant use (20%), alcohol abuse (17%), severe renal failure (17%), and thrombocytopenia (7%). Mean size of SDH in patients requiring surgery was 1.6 cm with 0.8 cm of midline shift. CONCLUSION: This study identified the pattern of mild TBI associated with neurological worsening at our Level I Trauma Center. Among patients with mild TBI, SDH patients seem to be at highest risk for deterioration and requirement for surgery. If these results can be externally validated through a multi-center study, these patients could be selectively identified for aggressive monitoring in the intensive care unit (ICU) and repeat CT scans.

A Comprehensive Assessment of Vascular and Nonvascular Risk Factors Associated with Migraine.

INTRODUCTION:  Migraine is a chronic disabling neurological disease, with an estimated expense of $15-20 million/year. Several studies with a small number of patients have studied risk factors for migraine such as cardiovascular disorders, stroke, smoking, demographic, and genetic factors but this is the first comprehensive study for evaluation of vascular and nonvascular risk factors. It is important to evaluate all the risk factors that help to prevent the healthcare burden related to migraine.  Methodology: We performed a retrospective cross-sectional analysis of the Nationwide Inpatient Sample (NIS) (years 2013-2014) in adult (>18-years old) hospitalizations in the United States. Migraine patients were identified using ICD-9-CM code to determine the demographic characteristics, vascular, and nonvascular risk factors. Univariate analysis was performed using the chi-square test and a multivariate survey logistic regression analysis was performed to identify the prevalence of the risk factors and evaluate the odds of prevalence of risk factors amongst migraine patients compared to nonmigraine patients, respectively. RESULTS:  On weighted analysis, after removing missing data of age, gender and race, from years 2013 to 2014, of the total 983,065 (1.74%) migraine patients were identified. We found that younger (median age 48-years vs. 60-years), female (82.1% vs. 58.5%; p<0.0001), white population (76.8% vs. 70.5%; p<0.0001), and privately insured (41.1% vs. 27.4%; p<0.0001) patients were more likely to have migraine than others. Cerebral atherosclerosis, diabetes mellitus, ischemic heart disease, atrial fibrillation, and alcohol abuse were not significantly associated with migraine. Migraineurs had higher odds of having hypertension [odds ratio (OR): 1.44; 95% confidence interval (CI): 1.43-1.46; 44.49% vs. 52.84%], recent transient ischemic attack (TIA) (OR: 3.13; 95%CI: 3.02-3.25; 1.74% vs. 0.67%), ischemic stroke (OR: 1.40; 95%CI: 1.35-1.45; 2.06% vs. 1.97%), hemorrhagic stroke (OR: 1.11; 95%CI: 1.04-1.19; 0.49% vs. 0.46%), obesity (OR: 1.46; 95%CI: 1.44-1.48; 19.20% vs. 13.56%), hypercholesterolemia (OR: 1.33; 95%CI: 1.30-1.36; 5.75% vs. 5.54%), substance abuse (OR: 1.51; 95%CI: 1.48-1.54; 7.88% vs. 4.88%), past or current consumption of tobacco (OR: 1.40; 95%CI: 1.38-1.41; 31.02% vs. 27.39%), AIDS (OR: 1.13; 95%CI: 1.04-1.24; 0.33% vs. 0.41%), hypocalcemia (OR: 1.09; 95%CI: 1.03-1.14; 0.77% vs. 0.89%), and vitamin D deficiency (OR: 1.93; 95%CI: 1.88-1.99; 2.47% vs. 1.37%) than patients without migraine. Female patients were at a higher risk of migraine (OR: 3.02; 95%CI: 2.98-3.05) than male. CONCLUSION:  In this study, we have identified significant risk factors for migraine hospitalizations. Early identification of these risk factors may improve the risk stratification in migraine patients.

Angioinvasive Aspergillus-associated Stroke in an Immunocompetent Host Following Cardiac Surgery and ECMO.

INTRODUCTION: Invasive cerebral aspergillosis is an uncommon cause of stroke among immunocompetent patients and has not been reported in association with cardiac surgery or extracorporeal membrane oxygenation (ECMO). We report the case of an immunocompetent host who developed aspergillus-associated stroke following coronary artery bypass graft (CABG) and ECMO. CASE REPORT: A 59-year-old woman developed cardiogenic shock after 3-vessel-CABG requiring intra-aortic balloon pump placement and subsequent veno-arterial ECMO. Noncontrast computed tomography of the brain was suggestive of multiple bihemispheric ischemic infarcts. Postmortem pathologic analysis revealed aspergillus-associated inflammation of blood vessels and ischemic and petechial hemorrhagic strokes in the affected territories. DISCUSSION AND CONCLUSIONS: Ischemic infarcts in the setting of CABG or ECMO are often presumed to be thromboembolic from the heart or device, related to underlying hemodynamic instability, or due to a clinically apparent systemic infection such as endocarditis. This report suggests that invasive cerebral aspergillosis should be considered in seemingly immunocompetent patients following CABG or ECMO. The mechanism is unclear, but may be related to systemic inflammatory dysregulation resulting in increased susceptibility to uncommon pathogens.