Early vs late anticoagulation in acute ischemic stroke with indications outside atrial fibrillation.

BACKGROUND: Current literature lacks guidance on the safety of administering anticoagulation in acute ischemic stroke with emergent indications that require anticoagulation other than atrial fibrillation. Therefore, we tend to rely on studies investigating acute ischemic stroke in atrial fibrillation for anticoagulation recommendations. METHODS: We retrospectively reviewed data for patients with acute ischemic stroke who had a non-atrial fibrillation emergent indication for anticoagulation (e.g., intra-arterial thrombus, intracardiac thrombus, acute coronary syndrome, acute limb ischemia, deep vein thrombosis and pulmonary embolism) diagnosed within 3 days of acute ischemic stroke. Patients who received anticoagulation ≤ 3 days of stroke onset (Group A) were compared to those who either received it afterwards or did not receive it at all (Group B). RESULTS: Out of the 558 patients, only 88 patients met our inclusion criteria. Of the total cohort, 55.7 % patients were males, and basic demographics were similar in both groups except for milder strokes in Group A (national institute of health stroke scale 6 vs. 12.5, p = 0.03). Only 2 patients in Group A and 1 patient in Group B developed intracranial hemorrhage, which was not statistically significant. Group A patients had a lower incidence of both new diagnosis (2 % vs. 34.2 % %, p < 0.001) and propagation of an established venous thromboembolism. They also had a lower rate of any thromboembolic complication (2 % vs. 42 %, p < 0.001). CONCLUSION: Early anticoagulation (i.e., ≤ 3 days) in non-atrial fibrillation ischemic stroke patients with an emergent indication may be safe and carry a lower risk of thromboembolic complications than later anticoagulation.

Anticoagulation Therapy in a Patient who had two Consecutive Strokes After Antibiotic Therapy for Infective Endocarditis: A Case Report.

A 77-year-old male presented with altered mentation and was diagnosed with infective endocarditis. Echocardiography revealed aortic valve vegetations. While receiving inpatient antibiotic therapy, the patient experienced an acute ischemic stroke. Magnetic resonance imaging of the brain showed punctate embolic-appearing infarcts in the right cerebellum and in the left occipital, frontal, and parietal lobes. Anticoagulation was not initiated due to a high risk of hemorrhagic transformation. He was readmitted after being discharged due to another episode of altered mentation. Repeat echocardiography indicated increased size of aortic valve vegetations. The patient was then transferred to our hospital for surgical intervention of enlarging vegetations, however was deemed unsuitable for surgery. During hospitalization, he suffered another embolic stroke in the right frontal lobe. By this time, the patient had completed a full course of antibiotics for infective endocarditis, and additional antibiotics were deemed unnecessary by our infectious disease specialists. Literature review highlighted that residual vegetations carry a higher risk for stroke, but no clear guidelines were found on how to intervene or assess the risk of hemorrhage with anticoagulation in this population. Consequently, a decision was made to initiate anticoagulation, Follow-up imaging revealed no evidence of hemorrhagic transformation. Subsequently, the patient remained stable and was discharged to a rehabilitation center, where he did not experience any further events.

Guidezilla Catheter in Neuroendovascular Interventions: A Case Series Study.

BACKGROUND: Neuroendovascular procedures can be challenging due to severe angulation of the cervical and cranial vessels. Typical approaches for overcoming this tortuosity involve using multiple telescoping catheter systems to provide proximal support for therapeutic device delivery. Although this approach can be effective, it does have limitations. METHODS: We describe the utility of the Guidezilla (Boston Scientific, Natick, Massachusetts, USA) guide extension catheter, a device designed for coronary interventions, in the treatment of 3 patients undergoing neuroendovascular procedures. RESULTS: In these 3 cases, the decision to use a guide extension catheter varied but was mainly due to severe tortuosity, heavy calcifications, and failure to introduce stents into distal locations. CONCLUSIONS: Although helpful in overcoming challenging anatomy, the Guidezilla guide extension catheter should be used with caution when used as a bailout device.

Spinal procedures, pneumocephalus, and cranial nerve palsies: A review of the literature.

Purpose: Minimally invasive and surgical spine procedures are commonplace with various risks and complications. Cranial nerve palsies, however, are infrequently encountered, particularly after procedures such as lumbar punctures, epidural anesthesia, or intrathecal injections, and are understandably worrisome for clinicians and patients as they may be interpreted as secondary to a sinister etiology. However, a less commonly considered source is a pneumocephalus which may, in rare cases, abut cranial nerves and cause a palsy as a benign and often self-resolving complication. Here, we present the case of a patient who underwent an intrathecal methotrexate infusion for newly diagnosed non-Hodgkin's T-cell lymphoma and subsequently developed an abducens nerve palsy due to pneumocephalus. We highlight the utility of various imaging modalities, treatment options, and review current literature on spinal procedures resulting in cranial nerve palsies attributable to pneumocephalus presenting as malignant etiologies.

Non-stenosing carotid artery plaques in embolic stroke of undetermined source: a retrospective analysis.

BACKGROUND: We aim to identify the association between high-risk carotid plaques and their laterality to stroke in ESUS patient population. We also discuss recurrent stroke events and their laterality to the index stroke. METHODS: This was a retrospective study. We reviewed data for patients with ESUS between June 20, 2016, and June 20, 2021. Using computed tomography angiography, we analyzed plaque features that are associated with ESUS, and then, we identified the recurrent stroke events and characterized lateralization to the index stroke. RESULTS: Out of 1779 patients with cryptogenic ischemic stroke, we included 152 patients who met the criteria for ESUS. High-risk plaque features were found more often ipsilateral to the stroke side when compared contralaterally: plaque ulceration (19.08% vs 5.26%, p < .0001), plaque thickness > 3 mm (19.08% vs 7.24%, p = 0.001), and plaque length > 1 cm (13.16% vs 5.92%, p = 0.0218). There was also a significant difference in plaque component in which both components (soft and calcified) and only soft plaques were more prevalent ipsilaterally (42.76% vs 23.68% and 17.76% vs 9.21%, respectively, p < .0001). Of the 152 patients, 17 patients were found to have a recurrent stroke event, and 47% (n = 8) had an ipsilateral stroke to the index event. Moreover, stroke was bilateral in 41% of the patients (n = 7), and contralateral in 12% (n = 2). CONCLUSION: High-risk plaque features studied here were more prevalent ipsilaterally to the stroke side in ESUS than contralaterally. Multicenter studies are needed to form precise prediction models and scoring systems to help guide treatment, i.e., choice of medical therapy and/or revascularization.

The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature.

PURPOSE: Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). METHODS: We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. CONCLUSION: Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.

Spinal Epidural Lipomatosis Causing Lumbar Canal Stenosis: A Pictorial Essay on Radiological Grading and the Role of Bariatric Surgery Versus Laminectomy.

Spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of adipose tissue in the spinal canal that can have a compressive effect on intraspinal neuroanatomical structures, leading to clinical symptoms. Several different conservative and surgical treatment strategies have been proposed but the treatment and outcomes remain controversial. There is a lack of severity-based evidence documenting the success of decompressive laminectomy in SEL and there are only anecdotal reports of clinico-radiological success with weight loss from bariatric surgery. This article demonstrates the resolution of SEL in two patients with bariatric surgery with the help of pre and postoperative MR imaging. The authors also highlight the classic "types" of spinal epidural lipomatosis with a surgically relevant grading system and elucidate the existence of concurrent extraspinal lipomatosis (i.e. mediastinal and intra-abdominal lipomatosis), drawing parallels with the natural history of SEL. The controversial question remains whether a symptomatic SEL patient needs a multilevel laminectomy for spinal decompression or bariatric surgery that can indirectly help the spinal condition. We propose that bariatric intervention could be better frontline management in patients with multifocal/multisystem lipomatosis (i.e., combined spinal and extraspinal) and spinal decompression would be ideal for those SEL patients with coexisting bony and/or ligamentous spinal canal or foraminal stenosis. This manuscript serves as a comprehensive and contemporary update on the radiological profile and two plausible treatment paths and will look toward further verification by a randomized clinical trial.

Pipeline Embolization Stent for the Treatment of Giant Supraclinoid Aneurysms: A Case Series.

Cerebrovascular aneurysms of the supraclinoid region are a technical challenge and can be particularly difficult to treat when greater than 25 mm in diameter. Such giant aneurysms can be approached with various skull-based and endovascular surgical techniques, and the advent of the Pipeline embolization stent presents a new treatment modality. Previously used for the treatment of small aneurysms, the Pipeline embolization device (PED) is a flow diverter device that has more recently been investigated in its use for the treatment of giant aneurysms with few studies to date published about its procedural outcomes. Here, we highlight the case of three patients (two elderly and one middle-aged) presenting symptomatically with giant supraclinoid aneurysms of the cavernous internal carotid artery (ICA) and posterior communicating artery treated with the Pipeline stent and monitored on follow-up visits. We further review the most current case reports and the two clinical trials to date investigating the utility of the Pipeline stent in the treatment of large and giant cerebral aneurysms, highlighting the emerging evidence of its efficacy and long-term patient outcomes. We report successful resolution of symptoms and radiographic evidence of aneurysm size reduction on all patient follow-ups and suggest the Pipeline embolization device as a novel technique that can be utilized for the treatment of giant cerebrovascular aneurysms with emerging evidence of immediate and long-term success.

Chemotherapy as Treatment for Acute Myeloid Leukemia (AML)-Induced Facial Nerve Palsy.

Acute myeloid leukemia (AML) is a disorder of the myeloid cell line that can manifest infrequently as a granulocytic sarcoma with infiltration into bone and soft tissue. Consequently, cranial nerve neuropathy due to AML infiltration can result in variable neurological deficits, including facial nerve palsy. Here, we present the case of a patient presenting with unilateral facial nerve palsy with evidence of AML in cerebrospinal fluid (CSF) cytology and bilateral opacification of the mastoid air cells suggestive of AML infiltration into the mastoid process. Patient demonstrated improvement of facial palsy after administration of intrathecal chemotherapy without need for surgical intervention. We further examine known cases reported to date on the use of chemotherapy and surgical intervention in management of facial nerve palsy as a consequence of AML infiltration of the mastoid bone. Notably, there appears to be a correlation between mastoid bone infiltration seen on imaging and facial nerve palsy in patients with known history of AML that may be treated without need for surgical intervention or biopsy.

Retro-Odontoid Intradural Synovial Cyst Decompression via Endoscopic-Assisted Far-Lateral Approach C1-C2 Hemilaminectomy Without Fusion: The Use of Intracranial Denticulate Ligament as Intraoperative Landmark.

Purely intradural retro-odontoid synovial cysts are rarely reported in neurosurgical literature, particularly in the absence of associated bony erosions. We present the case of a 57-year-old Native American male with a retro-odontoid synovial cyst and a history of chronic refractory neck pain that was adequately decompressed via an endoscopic-assisted far-lateral approach using a C1-2 hemilaminectomy, obviating the vertebral artery (VA) transposition, bony instability, and the need for instrumented bony fusion. The patient presented to our clinic with several months of refractory nuchal and cervical spine pain and crepitation affecting his activities of daily living (ADL). MRI findings revealed an intradural cyst at the level of C2 behind the odontoid process impinging on the medulla and causing early VA displacement. Both stereotactic neuro-navigation and microsurgical visualization aided in the manipulation of the endoscope and attaining the caudocranial working trajectory. The patient remained neurologically non-lateralizing postoperatively, similar to his preoperative status. This article highlights a less invasive surgical exposure with an endoscope-assisted caudocranial trajectory obtained by a limited unilateral hemilaminectomy to achieve the desired outcome.

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.

PAMAM Dendrimer Nanomolecules Utilized as Drug Delivery Systems for Potential Treatment of Glioblastoma: A Systematic Review.

Glioblastoma (GB) is a grade IV astrocytoma that maintains a poor prognosis with respect to current treatment options. Despite major advancements in the fields of surgery and chemoradiotherapy over the last few decades, the life expectancy for someone with glioblastoma remains virtually unchanged and warrants a new approach for treatment. Poly(amidoamine) (PAMAM) dendrimers are a type of nanomolecule that ranges in size (between 1 and 100 nm) and shape and can offer a new viable solution for the treatment of intracranial tumors, including glioblastoma. Their ability to deliver a variety of therapeutic cargo and penetrate the blood-brain barrier (BBB), while preserving low cytotoxicity, make them a favorable candidate for further investigation into the treatment of glioblastoma. Here, we present a systematic review of the current advancements in PAMAM dendrimer technology, including the wide spectrum of dendrimer generations formulated, surface modifications, core modifications, and conjugations developed thus far to enhance tumor specificity and tumor penetration for treatment of glioblastoma. Furthermore, we highlight the extensive variety of therapeutics capable of delivery by PAMAM dendrimers for the treatment of glioblastoma, including cytokines, peptides, drugs, siRNAs, miRNAs, and organic polyphenols. While there have been prolific results stemming from aggressive research into the field of dendrimer technology, there remains a nearly inexhaustible amount of questions that remain unanswered. Nevertheless, this technology is rapidly developing and is nearing the cusp of use for aggressive tumor treatment. To that end, we further highlight future prospects in focus as researchers continue developing more optimal vehicles for the delivery of therapeutic cargo.

Procedural outcomes of deep brain stimulation (DBS) surgery in rural and urban patient population settings.

Presently, disparities exist between race, sex, socioeconomic status, hospitals, income, comorbidities, and insurance profiles of patients undergoing DBS surgery. Here, we aim to highlight several variables and their predictive powers of DBS surgery outcomes as measured by dischargelocation, length of hospital stays, and total hospital charges. A retrospective cohort study using discharge data from NIS and HCUP for analyses and regression model statistics is performed. Comparative analyses demonstrate urban patients were more often non-routinely discharged, possessed private insurance, and accrued greater hospital costs compared to rural patients. Moreover, regression analyses predicts urban patients have 70% lower odds of routine discharge while those with a major loss of function prior to surgery also have 81% lower odds of routine discharge compared to those with minor loss of function. Ultimately, our study found urban patients or patients with major illnesses have higher hospital charges, longer hospitalization, and more often non-routinely discharged.

Disparities and Variables Associated With Physical Restraint for Acute Agitation in a Nonpsychiatric Emergency Department.

OBJECTIVE: To determine associations between the rate of physical restraint and demographic variables such as body mass index (BMI), ethnicity, sex, and age in the emergency department (ED) along with clinical variables such as various psychiatric diagnoses and medications. METHODS: This 6-month (October 1, 2016-March 30, 2017) retrospective chart review was conducted in the ED of a community hospital, which is also a teaching institution for medical students and residents but does not have access to psychiatry consultations via phone or in person. A total of 165 agitated patients were included in the study. Agitated patients who were restrained were compared to those who were not physically restrained. RESULTS: Of the patients, 112 (68%) were physically restrained, and those not physically restrained were included as controls (n = 53, 32%). Younger age (P = .03), lower BMI (P = .04), intoxication (P = .001), preexisting diagnosis of depression (P = .02), and antipsychotics as a home medication (P = .03) were associated with physical restraints. In the ED, administration of haloperidol and olanzapine was associated with physical restraints. Current benzodiazepine prescription (P = .001), ED administration of ketamine (P = .001), and ED administration of diazepam (P = .001) were more common in those not physically restrained. CONCLUSIONS: Risk factors for physical restraints can be used to identify high-risk patients early, and other treatments along with behavioral and environmental modifications may then be utilized. Further research to develop protocols using nonpharmacologic and pharmacologic measures to minimize use of restraints is required.

History of cerebral localization and the emigration plight of three neuroscience giants from Nazi Germany: Josef Gerstmann, Adolf Wallenberg, and Franz Josef Kallmann.

The Nazi regime held power for well over a decade in Germany and were steadfast in their anti-Semitic agenda. Among the massive cohort of immigrants to America were approximately 5056 Jewish physicians, including several highly esteemed neurologists and neuroscientists of the time. Emigrating to a new world proved difficult and provided new challenges by way of language barriers, roadblocks in medical careers, and problems integrating into an alien system of medical training and clinical practice. In this article, the authors examine the tumultuous and accomplished lives of three Jewish German and Austrian neurologists and neuroscientists during the time of the Third Reich who shaped the foundations of neuroanatomy and neuropsychology: Josef Gerstmann, Adolf Wallenberg, and Franz Josef Kallmann. The authors first examine the successful careers of these individuals in Germany and Austria prior to the Third Reich, followed by their journeys to and lives in the United States, to demonstrate the challenges an émigré physician faces for career opportunities and a chance at a new life. This account culminates in a description of these scientists' eponymous syndromes.Although their stories are a testimony to the struggles in Nazi Germany, there are intriguing and notable differences in their ages, ideologies, and religious beliefs, which highlight a spectrum of unique circumstances that impacted their success in the United States. Furthermore, in this account the authors bring to light the original syndromic descriptions: Gerstmann discovered contralateral agraphia and acalculia, right-left confusion, and finger agnosia in patients with dominant angular gyrus damage; Wallenberg described a constellation of symptoms in a patient with stenosis of the posterior inferior cerebellar artery; and Kallmann identified an association between hypogonadotropic hypogonadism and anosmia based on family studies. The article also highlights the unresolved confusions and international controversies about these syndromic descriptions. Still, these unique cerebral syndromes continue to fascinate neurologists and neurosurgeons across the world, from residents in training to practicing clinicians and neuroscientists alike.

miR-132/212 Modulates Seasonal Adaptation and Dendritic Morphology of the Central Circadian Clock.

The central circadian pacemaker, the suprachiasmatic nucleus (SCN), encodes day length information by mechanisms that are not well understood. Here, we report that genetic ablation of miR-132/212 alters entrainment to different day lengths and non-24 hr day-night cycles, as well as photoperiodic regulation of Period2 expression in the SCN. SCN neurons from miR-132/212-deficient mice have significantly reduced dendritic spine density, along with altered methyl CpG-binding protein (MeCP2) rhythms. In Syrian hamsters, a model seasonal rodent, day length regulates spine density on SCN neurons in a melatonin-independent manner, as well as expression of miR-132, miR-212, and their direct target, MeCP2. Genetic disruption of Mecp2 fully restores the level of dendritic spines of miR-132/212-deficient SCN neurons. Our results reveal that, by regulating the dendritic structure of SCN neurons through a MeCP2-dependent mechanism, miR-132/212 affects the capacity of the SCN to encode seasonal time.