Association of Prior Stroke With Health Care Perceptions of Adequate Emergency Care in Women.

BACKGROUND: Women with a history of stroke represent a vulnerable patient population due to their extant disability, morbidity, and risk of recurrence. The association between prior stroke with patient experience and perception of emergency medical care is unknown. METHODS: We utilized data from the Health Care Experiences and Perception cross-sectional, online survey from the American Heart Association Research Goes Red Registry. Ordinal logistic regression models were performed to assess the association between a self-reported history of stroke in the prior 10 years and the perception of not receiving adequate care in an emergency department because of gender or race. Models were adjusted for age at the time of enrollment, race/ethnicity, myocardial infarction within 10 years, and current smoking status. RESULTS: A total of 3498 women participants met inclusion criteria: 89 participants with a history of stroke in the past 10 years (mean age, 49.4 years; 10.1% Black participants and 5.6% Hispanic participants) and 3409 participants without such history (mean age, 45.8 years; 7.8% Black participants and 7.0% Hispanic participants). In multivariate logistic regression models, stroke history was significantly associated with greater odds of answering "to a great extent" that "I will not receive adequate care in an emergency room based on my gender" (odds ratio, 3.23 [95% CI, 1.69-6.17]) and "…race/ethnicity" (odds ratio, 3.88 [95% CI, 1.45-10.39]). Similar results were seen for secondary outcomes. CONCLUSIONS: Women patients with a stroke history felt less likely to receive adequate emergency care based on gender and race/ethnicity. Whether these negative health perceptions are associated with delays in presentation for stroke or other time-sensitive conditions should be the focus of future studies, given that these populations are known to less frequently receive advanced therapies for stroke, in part due to delays in presentation.

Diffusion-Restricted Lesions of the Splenium: Clinical Presentation, Radiographic Patterns, and Patient Outcomes.

Background and Objectives: Diffusion-restricted (DR) lesions of the splenium are encountered in a wide variety of pathologies, and their significance is often unclear. We sought to report the spectrum of clinical presentations, neuroimaging patterns, and the predictors of radiographic and clinical outcomes from DR splenial lesions. Methods: This was a single-center, retrospective cohort study from January 1, 2009, to August 1, 2020. A consecutive sample of 3,490 individuals who underwent brain MRI with reported corpus callosum lesions during the study period were evaluated for DR lesions in the corpus callosum. DR lesions were defined as increased signal intensity on diffusion-weighted imaging sequences with decreased signal intensity on apparent diffusion coefficient. Patients with prior neurosurgical procedures, hemorrhage-associated DR, anoxic brain injury, and chronic or previously known or characterized disease processes in the corpus callosum were excluded. Clinical and radiologic outcomes were ascertained, including readmissions within 1 year, in-hospital mortality rates, and resolution of DR at first follow-up imaging. Outcomes were defined a priori. Results: Two hundred patients met criteria for inclusion. The average age was 57 years (standard deviation 19 years). Near half of the patients were women (47%). Encephalopathy (55%), focal weakness (46.5%), and cortical signs (44%) were the most common presenting clinical features. Thirty-five cases (17.5%) had features consistent with cytotoxic lesions of the corpus callosum (CLOCCs). Vascular causes were most frequent (61%), followed by malignancy-related (15%) and trauma (8%). In-hospital mortality occurred in 8.5% of cases, 46.5% were readmitted to the hospital within 1 year, and 49.1% of patients had resolution of the splenial DR at the next scan. Backward stepwise regression models showed that mass effect was negatively associated with splenial DR resolution (odds ratio [OR]: 0.12, confidence interval [CI] 0.03-0.46, p = 0.002). Encephalopathy was significantly associated with in-hospital mortality (OR: 4.50, CI 1.48-17.95, p = 0.007). Patients with a CLOCC had less frequent readmissions at 1-year compared with patients without a CLOCC, p = 0.015. Discussion: Vascular DR lesions of the splenium were more common than CLOCCs and other etiologies in this cohort. While splenial DR lesions can present a clinical challenge, their associated clinical and radiographic characteristics may predict outcome and guide prognosis.

Clinical Problem-Solving: Lower Extremity Weakness & Paresthesia in an Immunocompromised Patient With a Complex Cancer History.

We present a case of new onset bilateral lower extremity weakness, paresthesia, urinary retention and bowel incontinence in a 51-year-old man. He had a complicated history of acute myelogenous leukemia with known central nervous system (CNS) and leptomeningeal involvement status post allogenic stem cell transplant complicated by chronic graft versus host disease (GVHD). We review the differential diagnosis as the physical exam and diagnostic results evolved. We also provide a review of the relevant literature supporting our favored diagnosis, as well as other competing diagnoses in this complicated case. The ultimate differential diagnosis included viral myelitis, treatment-related myelopathies, and CNS GVHD. The case provides a sobering reminder that even with an appropriate diagnostic workup, some cases remain refractory to therapeutic efforts. It also underscores the importance of a sensitive neurologic exam, given the significant clinico-radiological delay, and reviews the complex differential diagnosis for myelopathy.