Nicotine replacement therapy after subarachnoid hemorrhage is not associated with increased vasospasm.

BACKGROUND AND PURPOSE: A significant number of patients with aneurysmal subarachnoid hemorrhage are active smokers and at risk for acute nicotine withdrawal. There is conflicting literature regarding the vascular effects of nicotine and theoretical concern that it may worsen vasospasm. The literature on the safety of nicotine replacement therapy and its effects on vasospasm is limited. METHODS: A retrospective analysis was conducted of a prospectively collected database of aneurysmal subarachnoid hemorrhage patients admitted to the neurointensive care unit from 1994 to 2008. Paired control subjects matched for age, sex, Fisher score, aneurysm size and number, hypertension, and current medication were analyzed. The primary outcome was clinical and angiographic vasospasm and the secondary outcome was Glasgow Outcome Score on discharge. Conditional logistic models were used to investigate univariate and multivariate relationships between predictors and outcome. RESULTS: Two hundred fifty-eight active smoking patients were included of which 87 were treated with transdermal nicotine replacement therapy. Patients were well matched for age, sex, gender, Fisher score, aneurysm size and number, hypertension, and current medications, but patients who received nicotine replacement therapy had less severe Hunt-Hess scores and Glasgow coma scores. There was no difference in angiographic vasospasm, but patients who received nicotine replacement therapy were less likely to have clinical vasospasm (19.5 versus 32.8%; P=0.026) and a Glasgow Outcome Score <4 on discharge (62.6% versus 81.6%; P=0.005) on multivariate analysis. CONCLUSIONS: Nicotine replacement therapy was not associated with increased angiographic vasospasm and was associated with less clinical vasospasm and better Glasgow Outcome Score scores on discharge.

Left Ventricular Noncompaction Cardiomyopathy as a Potential Cause of Bilateral Posterior Cerebral Artery Stroke - a Rare and Unique Clinical Occurrence.

BACKGROUND Bilateral posterior cerebral artery (PCA) occlusions are exceedingly rare, and are considered a devastating phenomenon that presents as cortical blindness. Predominant causes of PCA infarcts include cardiac and arterial embolisms. Left ventricular noncompaction (LVNC) cardiomyopathy is also an extremely rare cardiopathology. Several reports describe stroke as a potential manifestation of LVNC, but bilateral PCA infarcts are likely also caused by underlying LVNC cardiomyopathy, although this has not yet been reported. CASE REPORT A 63-year-old man presented to the emergency department of an outside hospital with acute vision loss in both eyes and dysarthria. His neurological examination necessitated an emergent stroke evaluation. His electrocardiogram and telemetry at admission did not reveal arrhythmia. He underwent an emergency endovascular thrombectomy at our facility. During the post-intervention stroke workup, a transthoracic echocardiogram with contrast showed left ventricle dilation, with an ejection fraction (EF) of 29%. Subsequent cardiac magnetic resonance imaging confirmed the presence of LVNC cardiomyopathy. He was started on therapeutic anticoagulation (apixaban) and remained stable neurologically during the 3-month followup, with some residual visual field deficits. His cardiac outcome also improved (stress test was unremarkable for any cardiac ischemia, and an echocardiogram showing improved EF of 40%). CONCLUSIONS Our report is distinct, as it presents 2 exceedingly rare events in a patient: the occurrence of simultaneous bilateral PCA infarcts and LVNC cardiomyopathy. Prompt and accurate diagnosis was pivotal to the successful management of both conditions. Prospective studies are warranted to further knowledge of LVNC pathophysiology and the occurrence of stroke in such patients so that comprehensive management plans can be devised.

Ultrasound-guided lumbar puncture improves success rate and efficiency in overweight patients.

BACKGROUND: Approximately 400,000 diagnostic lumbar punctures (LPs) are performed by neurologists yearly in the United States. There has been a transition from neurologists performing >40% of LPs 2 decades ago to now <15% of the time. High body mass index (BMI) is one of the key obstacles of LP for neurology residents, and the success rates drop to 58% when BMI is >35 kg/m2. METHODS: A prospective intervention study was conducted from March 2017 to March 2018 at an academic medical center. Patients were divided into ultrasound-guided LP or conventional LP. The primary outcome was the success rate of LP. The secondary outcome was the parameters regarding LP performance, the patients' feedback after procedures, and the residents' feedback about the learning modules. RESULTS: Eighty-two patients were enrolled with inclusion criteria of age >18 years, BMI ≥25 kg/m2, and able to give written informed consent. The ultrasound-guided LP group showed higher success rate (92.7% vs 68.3%, p < 0.05) and less duration of time (17.02 vs 37.63 minutes, p < 0.05) compared with the conventional LP group. It also showed advantages of decreased trials of needle insertions and redirections and reduced pain levels perceived by patients. CONCLUSIONS: This study suggests that using ultrasound to localize before LP could increase the LP success rate and improve other related LP outcomes in the overweight populations. Our study also provides evidence that brief, targeted teaching modules are feasible and effective for ultrasound-guided LP training. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with BMI ≥25 kg/m2 undergoing LP, ultrasound guidance increases the LP success rate.

Cortical Vein Thrombosis as a Mimic for Isolated Cortical Subarachnoid Hemorrhage and Transient Ischemic Attack.

Isolated cortical subarachnoid hemorrhage is rare and poorly understood. Differential diagnoses and proposed pathophysiology vary widely and the diagnostic work-up for these patients who present with transient ischemic attack-like episodes and characteristic imaging findings is still unclear. We report a case of isolated subarachnoid hemorrhage and transient neurologic deficits due to isolated cortical vein thrombosis that was not detected by noninvasive tests. A 75-year-old woman with a history of a lobar intracerebral hemorrhage presented to the Academic Medical Center with sudden-onset transient left upper extremity weakness. Head CT showed a linear hyperdensity in the right precentral gyrus suggestive of isolated subarachnoid hemorrhage. MRI showed susceptibility in the corresponding area. CT angiogram and MRV showed no evidence of a venous thrombosis. The main outcome measures were results of computerized tomography and CT angiogram, magnetic resonance parenchymal and vascular imaging, angiography findings and clinical follow-up at 3 months. Cortical vein thrombosis was detected on conventional angiography. MRI was negative for microhemorrhages. The patient was anticoagulated and had no recurrences of her symptoms. We conclude that cortical vein thrombosis can present as isolated subarachnoid hemorrhage and transient ischemic attack-like episodes and may require angiography for definitive diagnosis.

Decompressive hemicraniectomy and durotomy for malignant middle cerebral artery infarction.

The high early case fatality among patients with massive hemispheric strokes calls for effective treatments. Release of the restriction created by the dura mater and bony skull to allow the infarcted brain tissue to swell has been successfully adopted by some while considered controversial by others. A recent pooled analysis provides estimates for the efficacy of decompressive surgery. Further analyses of current trial data suggest that in particular patient age and timing of surgery determine outcome. Nonetheless, in order to guide the management of individual patients, carefully adjusted medical care, ongoing futility analysis, and simultaneous caregiver meetings should be conducted to reach a joint decision addressing any ethical concerns. In conclusion, decompressive surgery increases the probability of survival but produces patients with moderate or moderately severe disability (albeit not severe disability). Currently, the decision to perform decompressive surgery should remain an individual one in each and every patient.