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.

Telemedicine for Acute Monocular Visual Loss: A Retrospective Large Telestroke Network Experience.

Introduction: Central retinal artery occlusion (CRAO) is an under-recognized stroke subtype that may benefit from hyperacute reperfusion therapies. We aimed to evaluate the ability of telestroke activations to provide CRAO diagnosis and thrombolysis. Methods: This retrospective observational study investigates all encounters conducted for acute visual loss between 2010 and 2021 in our multicentric Mayo Clinic Telestroke Network. Demographics, time from visual loss to telestroke evaluation, ocular examination, diagnostic, and therapeutic recommendations were collected for CRAO subjects. Results: Out of 9,511, 49 encounters (0.51%) were conducted for an acute ocular complaint. Five patients had possible CRAO, and 4 presented within 4.5 h from symptom onset (range 1.5-5 h). None received thrombolytic therapy. All telestroke physicians recommended ophthalmology consultation. Conclusion: Current telestroke assessment of acute visual loss is suboptimal and patients eligible for acute reperfusion therapies may not be offered treatment. Teleophthalmologic evaluations and advanced ophthalmic diagnostic tools should complement telestroke systems.

Migrainous infarction of the eye: Two cases of monocular ischemic complications associated with retinal migraine.

BACKGROUND: Retinal migraine is defined by fully reversible monocular visual phenomena. We present two cases that were complicated by permanent monocular vision deficits. CASES: A 57-year-old man with history of retinal migraine experienced persistent monocular vision loss after one stereotypical retinal migraine, progressing to finger-count vision over 4 days. He developed paracentral acute middle maculopathy that progressed to central retinal artery occlusion. A 27-year-old man with history of retinal migraine presented with persistent right eye superotemporal scotoma after a retinal migraine. Relative afferent pupillary defect and superotemporal visual field defect were noted, consistent with ischemic optic neuropathy. CONCLUSION: Retinal migraine can complicate with permanent monocular visual loss, suggesting potential migrainous infarction of the retina or optic nerve. A thorough cerebrovascular evaluation must be completed, which was unrevealing in our cases. Acute and preventive migraine therapy may be considered in retinal migraine patients, to mitigate rare but potentially permanent visual loss.

Prognostic Utility of Daily Changes in Glasgow Coma Scale and the Full Outline of Unresponsiveness Score Measurement in Patients with Metabolic Encephalopathy, Central Nervous System Infections and Stroke in Uganda.

BACKGROUND: Metabolic encephalopathy (ME), central nervous system (CNS) infections, and stroke are common causes of reduced level of consciousness in Uganda. However, the prognostic utility of changes in the daily measurements of the Full Outline of Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS) score in these specific disorders is not known. METHODS: We conducted secondary analyses of data from patients who presented with reduced level of consciousness due to CNS infections, stroke, or ME to a tertiary hospital in Uganda. Patients had FOUR/GCS scores at admission and at 24 and 48 h. We calculated a change in FOUR score (ΔFOUR) and change in GCS score (ΔGCS) at 24 and 48 h and used logistic regression models to determine whether these changes were predictive of 30-day mortality. In addition, we determined the prognostic utility of adding the admission score to the 24-h ΔFOUR and 24-h ΔGCS on mortality. RESULTS: We analyzed data from 230 patients (86 with ME, 79 with CNS infections, and 65 with stroke). The mean (SD) age was 50.8 (21.3) years, 27% (61 of 230) had HIV infection, and 62% (134 of 230) were peasant farmers. ΔFOUR at 24 h was predictive of mortality among those with ME (odds ratio [OR] 0.64 [95% confidence interval {CI} 0.48-0.84]; p = 0.001) and those with CNS infections (OR 0.65 [95% CI 0.48-0.87]; p = 0.004) but not in those with stroke (OR 1.0 [95% CI 0.73-1.38]; p = 0.998). However, ΔGCS at 24 h was only predictive of mortality in the ME group (OR 0.69 [95% CI 0.56-0.86]; p = 0.001) and not in the CNS or stroke group. This 24-h ΔGCS and ΔFOUR pattern was similar at 48 h in all subgroups. The addition of an admission score to either 24-h ΔFOUR or 24-h ΔGCS significantly improved the predictive ability of the scores in those with stroke and CNS infection but not in those with ME. CONCLUSIONS: Twenty-four-hour and 48-h ΔFOUR and ΔGCS are predictive of mortality in Ugandan patients with CNS infections and ME but not in those with stroke. For individuals with stroke, the admission score plays a more significant predictive role that the change in scores.

Stroke Mortality Outcomes in Uganda.

BACKGROUND AND PURPOSE: Stroke outcome data in Uganda is lacking. The objective of this study was to capture 30-day mortality outcomes in patients presenting with acute and subacute stroke to Mbarara Regional Referral Hospital (MRRH) in Uganda. METHODS: A prospective study enrolling consecutive adults presenting to MRRH with abrupt onset of focal neurologic deficits suspicious for stroke, from August 2014 to March 2015. All patients had head computed tomography (CT) confirmation of ischemic or hemorrhagic stroke. Data was collected on mortality, morbidity, risk factors, and imaging characteristics. RESULTS: Investigators screened 134 potential subjects and enrolled 108 patients. Sixty-two percent had ischemic and 38% hemorrhagic stroke. The mean age of all patients was 62.5 (SD 17.4), and 52% were female. More patients had hypertension in the hemorrhagic stroke group than in the ischemic stroke group (53% vs. 32%, p = 0.0376). Thirty-day mortality was 38.1% (p = 0.0472), and significant risk factors were National Institutes of Health Stroke Scale (NIHSS) score, female sex, anemia, and HIV infection. A one unit increase of the NIHSS on admission increased the risk of death at 30 days by 6%. Patients with hemorrhagic stroke had statistically higher NIHSS scores (p = 0.0408) on admission compared to patients with ischemic stroke, and also had statistically higher Modified Rankin Scale (mRS) scores at discharge (p = 0.0063), and mRS score change from baseline (p = 0.04). CONCLUSIONS: Our study highlights an overall 30-day stroke mortality of 38.1% in southwestern Uganda, and identifies NIHSS at admission, female sex, anemia, and HIV infection as predictors of mortality.

A comparison of the Full Outline of Unresponsiveness (FOUR) and Glasgow Coma Scale (GCS) Scores in Predicting Mortality Among Patients with Reduced Level of Consciousness in Uganda.

BACKGROUND: Reduced level of consciousness (LOC) is a common cause of presentation among acutely ill adults in sub-Saharan Africa and is associated with high rates of mortality. Although the Full Outline of Unresponsiveness (FOUR) score is often used in clinical practice, its utility in predicting mortality has not been assessed in the region. METHODS: We prospectively enrolled adults presenting with reduced LOC to Mbarara Regional Referral Hospital in Uganda. We recorded clinical and laboratory data and performed the FOUR and Glasgow Coma Scale (GCS) scores at admission. We used survival analysis, fit Cox proportional hazards regression models to assess the predictive properties of the two scores, and compared their performance using area under the receiver operating characteristic curve (AUROC). RESULTS: We enrolled 359 patients, mean (SD) age was 51 (22.2) years, and 58% (210/359) were male. The median (interquartile range) admission FOUR and GCS scores were 13.0 (3.0-16.0) and 10.0 (3.0-14.0), respectively. Subjects with the FOUR score of 0-11 had a 2.6-fold higher hazard of 30-day mortality (HR 2.6, 95% CI 1.9-3.6, p < 0.001) compared to those with the score of 12-16. Those with the GCS score of 3-8 had a 2.7-fold higher hazard of 30-day mortality (HR 2.7, 95% CI 2.0-3.8, p < 0.001) compared to those with the score of 9-15. The AUROC (95% CI) for the FOUR score and GCS score was 0.68 (0.62-0.73) and 0.67 (0.62-0.73), respectively (p = 0.825). CONCLUSIONS: The FOUR score is comparable to the GCS score in predicting mortality in Uganda. Our findings support the introduction of the FOUR score in guiding the management of patients with reduced LOC in sub-Saharan Africa.

The Dilemma of Resuming Antithrombotic Therapy After Intracranial Hemorrhage in Patients With Left Ventricular Assist Devices.

BACKGROUND/OBJECTIVE: Antithrombotic therapy is administered after left ventricular assist device (LVAD) implantation to prevent thromboembolic events. Intracranial hemorrhage (ICH) is a life-threatening adverse event requiring immediate discontinuation of antithrombotics. We investigated the timing of antithrombotic resumption after ICH in patients with LVADs and the association between timing and risk of recurrent hemorrhage and thrombotic events. METHODS: We performed a multicenter, retrospective analysis of patients with ICH occurrence during LVAD antithrombotic regimen with subsequent resumption of antithrombotics from January 1, 2010, to December 31, 2017. Covariates included age, international normalized ratio, antithrombotic dosing, timing of resumption, modified Rankin score, and subsequent hemorrhagic and thrombotic events within 1 year post-ICH. Patients who did not resume anticoagulation were excluded. RESULTS: Of 673 patients with LVADs, 85 (12.6%) developed ICH while being treated with antithrombotics. Forty-three were excluded due to death prior to resumption and one due to lack of resumption. The remaining 41 patients were on antithrombotics with a median (interquartile range [IQR]) international normalized ratio at ICH onset of 2.6 (1.8-3.6). Aspirin and warfarin were resumed at a median (IQR) of 5.5 (1.3-8.8) and 6.5 (4.0-15.5) days post-ICH, respectively. A continuous unfractionated heparin infusion was initiated in 16 (39.0%) patients at a median (IQR) of 2.5 (1.0-7.8) days post-ICH. During the 1-year follow-up after anticoagulation resumption, 11 (26.8%) patients suffered secondary hemorrhages and two (4.9%) suffered secondary thrombotic events. Using Kaplan-Meier method and log-rank test, we compared all patients who resumed anticoagulation by 6 days post-ICH to those who resumed after 6 days. There was no difference in freedom from secondary hemorrhagic event between the two groups (P = 0.75). CONCLUSION: Despite timing of resumption of antithrombotic therapy after ICH, recurrent hemorrhagic events can be expected in one-quarter of these patients over the subsequent year.

Telestroke Program Participation and Improvement in Door-To-Needle Times.

Background: Telestroke can provide indispensable expert stroke care for rural hospitals. The Stroke Telemedicine for Arizona Rural Residents program was developed in 2006 by Mayo Clinic to provide stroke expertise across the region. However, little data currently exist to determine whether this telestroke program had an impact on accepted acute stroke care metrics, such as door-to-needle time. Hypothesis: Participation of spoke sites in a telestroke program improves stroke care over time, as defined by currently accepted metrics, such as door-to-needle time. Methods: A retrospective analysis was performed on the telestroke database from Mayo Clinic Arizona between the years of 2011 to 2018. All patients with a diagnosis of acute ischemic stroke, who underwent a telestroke consultation and received intravenous alteplase were included in the analysis. Univariate linear regression was performed to look for associations between variables and defined outcomes. Results: A total of 563 patients were identified who met inclusion criteria. Average last-known normal to needle times decreased across all telestroke participating spoke sites from 176 to 147 min, with univariate linear regression showing a trend of decreased time of 3.4 min per year, which was statistically significant (p = 0.0042). Average door-to-needle times decreased from 112 to 81 min, with univariate linear regression modeling showing a decreasing trend of 3.7 min per year (p < 0.0001). Conclusions: Telestroke network participation may be associated with improved acute stroke care metrics over time, with the analysis illustrating improved last-known normal to needle and door-to-needle times among participating spoke sites.

Prediction of Delayed Cerebral Ischemia with Cerebral Angiography: A Meta-Analysis.

OBJECT: Cerebral catheter angiography is the gold standard for diagnosing cerebral artery vasospasm (vasospasm) in aneurysmal subarachnoid hemorrhage (SAH). We have previously published a meta-analysis of prediction of delayed cerebral ischemia (DCI) from transcranial Doppler (TCD) evidence of vasospasm. Analogous data relating to prediction of DCI have not been previously collated for cerebral angiography nor reconciled against TCD. METHODS: We searched PUBMED, the Cochrane database, and clinicaltrials.gov for studies that used cerebral angiography for diagnosis of vasospasm and evaluated DCI in patients with SAH. We performed a random-effects meta-analysis of prediction of DCI with cerebral angiography, reconciling its accuracy against that of TCD. We also report quality of evidence for the value of cerebral angiography and TCD in SAH based on pooled data from our meta-analyses. RESULTS: A total of 15 studies (n = 5463) were included in the meta-analysis. Sensitivity (SN), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of cerebral angiography for prediction of DCI are 57, 68, 32, and 90%. These metrics for TCD, based on our previous meta-analysis, are 90, 71, 57, and 92%. We report that test accuracy estimates are "moderate" for TCD and "low" for angiography based on pooled data from our meta-analyses. CONCLUSION: TCD evidence of vasospasm is a better predictor of DCI than angiographic vasospasm. Future comparative effectiveness studies can better define the value of these diagnostic tools in patients with SAH.

Validation of the Intracerebral Hemorrhage Score in Uganda.

Background and Purpose- Rates of intracerebral hemorrhage (ICH) are estimated to be highest globally in sub-Saharan Africa. However, outcomes of ICH are poorly described and standard prognostic markers for ICH have not been validated in the region. Methods- We enrolled consecutive patients with computed tomography-confirmed ICH at a referral hospital in southwestern Uganda. We recorded demographic, clinical, and radiographic features of ICH, and calculated ICH scores. We fit Poisson regression models with robust variance estimation to determine predictors of case fatality at 30 days. Results- We enrolled 73 individuals presenting with computed tomography-confirmed ICH (mean age 60 years, 45% [33/73] female, and 14% [10/73] HIV-positive). The median ICH score was 2 (interquartile range, 1-3; range, 0-5). Case fatality at 30 days was 44% (32/73; 95% CI, 33%-57%). The 30-day case fatality increased with increasing ICH score of 0, 1, and 5 from 17%, 23%, to 100%, respectively. In multivariable-adjusted models, ICH score was associated with case fatality (adjusted relative risk, 1.48; 95% CI, 1.23-1.78), as were HIV infection (adjusted relative risk, 1.92; 95% CI, 1.07-3.43) and female sex (adjusted relative risk, 2.17; 95% CI, 1.32-3.59). The ICH score moderately improved with the addition of a point each for female sex and HIV serostatus (0.81 versus 0.73). Conclusions- ICH score at admission is a strong prognostic indicator of 30-day case fatality in Uganda. Our results support its role in guiding the care of patients presenting with ICH in the region.

Stroke in Human Immunodeficiency Virus-infected Individuals in Sub-Saharan Africa (SSA): A Systematic Review.

BACKGROUND: Human immunodeficiency virus (HIV) infection is associated with worse outcomes after stroke, but this association is less well-described in sub-Saharan Africa (SSA). We reviewed literature on stroke among people living with HIV (PLWH) in SSA. METHODS: We systematically reviewed published literature for original clinical stroke studies conducted in SSA that included PLWH. We included studies that reported data on presenting characteristics, risk factors, and/or outcomes after stroke. RESULTS: Seventeen studies (N = 478) met inclusion criteria. At the time of stroke presentation, PLWH had a median age ranging from 32 to 43 years. Subjects had low CD4 counts (median CD4, 108-225 cells/µl), and most were antiretroviral therapy-naïve. Fever, seizures, and concurrent opportunistic infections were common at presentation. Ischemic stroke accounted for up to 96% of strokes, which were mostly located in the anterior circulation territory. In studies comparing PLWH with HIV-uninfected individuals, PLWH had more frequent coagulopathy, greater stroke severity, (72% versus 36% National Institutes of Health Stroke Scale >13, P = .02), longer hospital length of stay (30.5 versus <10 days), and a higher 30-day mortality rate (23% versus 10.5%, P = .007). CONCLUSION: Stroke in PLWH in SSA occurs at a young age, in those with advanced disease, and is associated with worse outcomes than in HIV-uninfected comparators. Stroke in young individuals in the region should prompt HIV testing, and ongoing efforts to promote early antiretroviral therapy initiation might also help decrease stroke incidence, morbidity, and mortality in the region.

Retinal Microvascular Abnormalities as Surrogate Markers of Cerebrovascular Ischemic Disease: A Meta-Analysis.

BACKGROUND: To determine the predictive value of retinal microvascular abnormalities for cerebrovascular ischemic diseases (CVDs), we aimed to investigate the quantitative association between retinal microvascular changes and CVD subcategories: white matter hyperintensities (WMHIs), lacunar infarcts (LIs), and cerebral infarctions (CIs). METHODS: Using Meta-analyses Of Observational Studies in Epidemiology guidelines, we searched 6 databases through September 2016 for studies evaluating the linkage between retinal microvascular abnormalities and WMHI, and LI and CI. Studies were included if they reported odds ratios (ORs) and 95% confidence intervals or raw patient level data (that were computed into ORs). Unadjusted and vascular risk-factor adjusted ORs were pooled into meta-analysis using DerSimonian Laird random effects model. Study quality and dissemination biases were assessed and integrated. RESULTS: From 24,444 search-identified records, 28 prospective studies encompassing 56,379 patients were eligible for the meta-analysis. After vascular risk-factor adjustment, focal arteriolar narrowing was associated with WMHI (OR, 1.24 [1.01-1.79]), LI (OR, 1.77 [1.14-2.74]), and CI (OR, 1.75 [1.14-2.69]). Venular dilation was associated with LI (OR, 1.46 [1.10-1.93]), and retinal hemorrhages with WMHI (OR, 2.23 [1.34-3.70]). Any retinopathy exhibited significant association with CI (OR, 1.96 [1.65-2.50]). Heterogeneity was significant (I2>50%) for all syntheses except retinal hemorrhages and WMHI, and retinopathy and CI (I2=0 ⋅ 0%). Associations remained significant after adjustments for quality and publication bias. CONCLUSIONS: We found the most significant association between retinal hemorrhages and WMHI. Focal arteriolar narrowing and retinopathy predicted CVD subtypes after risk-factor adjustment, suggesting that features different than traditional vascular risk factors, are involved in CVD pathophysiology.

Amyloid-Beta-Related Angiitis with Distinctive Neuro-Ophthalmologic Features.

Amyloid beta-related angiitis (ABRA) is a subtype of cerebral amyloid angiopathy-related inflammation, with distinctive pathology and prognosis compared with cerebral amyloid angiopathy (CAA). On a spectrum of increasing severity, ABRA is considered to be in-between the less aggressive inflammatory-CAA and the more severe primary central nervous system (CNS) angiitis. Whereas retinal pathological changes were described in subjects with primary or secondary CNS angiitis, and non-inflammatory CAA, bilateral posterior pole superficial and peripapillary retinal hemorrhages have not been reported as initial signs in patients with pathology-confirmed ABRA, accompanying neurological spells and characteristic neuroimaging findings.

Robotic telepresence versus standardly supervised stroke alert team assessments.

BACKGROUND: Telemedicine has created access to emergency stroke care for patients in all communities, regardless of geography. We hypothesized that there is no difference in speed of assessment between vascular neurologist (VN) robotic telepresence and standard VN-supervised stroke alert patients in a metropolitan primary stroke center. MATERIALS AND METHODS: A retrospective stroke alert database was used to identify all robotic telepresence and standardly supervised stroke alert patient assessments at a primary stroke center emergency department from 2009 to 2012. The primary outcome measure was the duration of assessment from stroke alert activation to treatment or downgrade. RESULTS: The sample size was 196 subjects. The mean duration of time from stroke alert activation to initiation of intravenous (IV) thrombolytic treatment or downgrade was 8.6 min longer in the robotic group than in the standard group (p=0.03). Among the subgroup of acute ischemic stroke patients treated with IV thrombolysis, the mean duration of time from activation to treatment was 18 min longer in the robotic group than in the standard group (p=0.01). Safety outcomes including thrombolysis protocol violations (0% versus 1%), post-thrombolysis symptomatic intracranial hemorrhagic complications (3% versus 1%), and death during hospitalization (8% versus 6%) were low in the robotic group and not significantly different from that in the standard group. CONCLUSIONS: Standard VN-supervised acute stroke team assessments were swifter than those supervised by robotic telepresence. Safety outcomes of robotic telepresence-supervised stroke alerts were excellent, and this modality may be preferred in circumstances when a VN is not immediately available on-site.

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.

Is Intravenous Immunoglobulin Effective in Reducing the Risk of Mortality and Morbidity in Neuroinvasive West Nile Virus Infection?: A Critically Appraised Topic.

BACKGROUND: The clinical benefit of intravenous immunoglobulin (IVIG) in adult individuals with neuroinvasive West Nile virus (niWNV) infection is not well substantiated. We sought to critically assess current evidence regarding the efficacy of IVIG in treating patients with niWNV. METHODS: The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of neuro-infectious diseases. RESULTS: The appraised study enrolled 62 participants with suspected niWNV, randomized into 3 different arms [37 participants in the Omr-IgG-am group, 12 in the Polygam group, and 13 in the normal saline (NS) group]. Omr-IgG-am and Polygam are different formulations of IVIG. IVIG safety, measured as rates of serious adverse events, was the primary study outcome while IVIG efficacy, measured as rates of unfavorable outcomes, was a secondary endpoint. The estimated rates of SAE were statistically similar in all groups (51.4% Omr-IgG-am, 58.3% Polygam, and 23.1% NS groups). Unfavorable outcomes also occurred at a similar rate between all the groups (51.5% Omr-IgG-am, 54.5% Polygam, and 27.3% NS). CONCLUSIONS: The appraised trial showed that Omr-IgG-am and Polygam are as safe as NS. Data on efficacy from this trial were limited by a small sample size. Phase III clinical trials on IVIG efficacy in NiWNV infection are needed.

Does Initiation of Prophylactic Antiseizure Medication Improve Neurological Outcomes in Patients With Acute Intracerebral Hemorrhage?: A Critically Appraised Topic.

OBJECTIVE: The objective of this study was to critically assess current evidence regarding the role of prophylactic antiseizure medication in patients presenting with acute intracerebral hemorrhage (ICH). 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 resident neurologists, a medical librarian, and content experts in the fields of epilepsy, stroke neurology, neurohospitalist medicine, and neurocritical care. RESULTS: A randomized clinical trial was selected for critical appraisal. The trial assessed whether prophylactic levetiracetam (LEV) use reduced the risk of acute seizures in patients with ICH, as defined by clinical or electrographic seizure, captured by continuous electroencephalogram 72 hours after enrollment. A total of 42 patients were included in the final analysis (19 in the LEV group and 23 in the placebo group). There was a significantly higher occurrence of seizures in the placebo versus LEV group (LEV 16% vs placebo 43%, P = 0.043). There were no differences in functional outcomes between the groups at 3, 6, or 12 months (P > 0.1). CONCLUSIONS: The role of prophylactic treatment with antiseizure medication in ICH remains unclear.

Blood pressure variability and early neurological outcomes in acute and subacute stroke in Southwestern Uganda.

Background: Greater blood pressure variability has detrimental effects on clinical outcome after a stroke; its effects are controversial and have not been evaluated in Sub-Saharan Africa (SSA). Methods: We conducted a prospective study of patients with CT head confirmed ischemic and hemorrhagic strokes admitted to a tertiary hospital within 7 days of onset of unilateral neurological deficits. Blood pressure variability indices, standard deviation (SD) and coefficient of variation (CV) of systolic and diastolic blood pressure between day 0 and day 7, were calculated with a subsequent modified Rankin Scale (mRS) score on day 14 post-stroke. Linear regression was performed to determine the exponential coefficients of mortality at 14 days post- stroke. Results: Out of 120 patients, 51.7% were female, 52.5% had ischemic stroke and the overall median age was 65 (IQR 54-80) years. Twenty (16.7%) patients died within a median survival time of 7 days, while 32 (26.7%) died by day 14 post-stroke. Patients with hemorrhagic stroke had an overall SDSBP of 16.44 mmHg while those with ischemic stroke had an overall SDSBP of 14.05 mmHg. In patients with ischemic stroke, SDSBP had adjusted coefficients of 1, p = 0.004 with C·I: 1.01-1.04 and NIHSS had adjusted coefficients of 1, p = 0.019 with C·I: 1.00-1.03 while in patients with hemorrhagic stroke, SDSBP had adjusted coefficients of 1, p = 0.045 with C·I: 1.00-1.04 and NIHSS had adjusted coefficients of 1, p ≤0.001 with C·I: 1.01-1.03. Conclusion: Exponential increase in Blood Pressure Variability (BPV) and stroke severity scale were independently associated with early mortality among all stroke patients in our study. We recommend future studies to evaluate whether controlling BPV among patients with stroke in Sub-Saharan Africa can reduce mortality.

HIV Infection and 90-Day Stroke Outcomes in Uganda: A Prospective Observational Cohort Study.

Background and Objectives: Little is known about the impact of HIV infection on the clinical presentation and outcomes after stroke in the modern antiretroviral therapy (ART) era. We aimed to compare stroke characteristics and outcomes between persons with HIV (PWH) and without HIV (PWOH) presenting with stroke in Uganda. Methods: We conducted a matched cohort study at Mulago National Referral Hospital and Mbarara Regional Referral Hospital between January 2018 and November 2020. We enrolled consecutive PWH presenting with CT-confirmed acute or subacute stroke (symptom onset ≤14 days) and matched them by sex and stroke type to 2 consecutive available PWOH admitted to the same hospital. We obtained baseline clinical data and followed participants for 90 days from the day of clinical presentation. We compared stroke severity (defined by the NIH stroke scale [NIHSS]) and 90-day all-cause mortality and morbidity (using the modified Rankin Scale [mRS]) by HIV serostatus with and without adjustment for confounders. Results: We enrolled 105 PWH and 157 PWOH with stroke. PWH were younger (mean [SD] age 49 [14] vs 59 [16] years, p < 0.001), and nearly 80% (82/105) were on ART for a median of 5 years and a median CD4 count of 214 cells/uL (interquartile range 140, 337). Compared with PWOH, PWH presented with a 3-point lower median NIHSS (16 vs 19, p = 0.011), a 20% lower proportion of all-cause mortality at 90 days (p = 0.001), and had less disability at 90 days (median mRS 4 vs 5, p = 0.004). Age and NIHSS-adjusted odds ratio of 90-day all-cause mortality in PWH compared with PWOH was 0.45 (95% CI 0.22-0.96, p = 0.037). Discussion: In the modern ART era, PWH with acute stroke in Uganda present with modest stroke and are significantly less likely to die within 90 days than PWOH. This potentially reflects the protective effects of ART, enhanced health care access, and their younger age at stroke presentation.

Consensus Competencies for Postgraduate Fellowship Training in Global Neurology.

BACKGROUND AND OBJECTIVES: Use a modified Delphi approach to develop competencies for neurologists completing ≥1 year of advanced global neurology training. METHODS: An expert panel of 19 United States-based neurologists involved in global health was recruited from the American Academy of Neurology Global Health Section and the American Neurological Association International Outreach Committee. An extensive list of global health competencies was generated from review of global health curricula and adapted for global neurology training. Using a modified Delphi method, United States-based neurologists participated in 3 rounds of voting on a survey with potential competencies rated on a 4-point Likert scale. A final group discussion was held to reach consensus. Proposed competencies were then subjected to a formal review from a group of 7 neurologists from low- and middle-income countries (LMICs) with experience working with neurology trainees from high-income countries (HICs) who commented on potential gaps, feasibility, and local implementation challenges of the proposed competencies. This feedback was used to modify and finalize competencies. RESULTS: Three rounds of surveys, a conference call with United States-based experts, and a semistructured questionnaire and focus group discussion with LMIC experts were used to discuss and reach consensus on the final competencies. This resulted in a competency framework consisting of 47 competencies across 8 domains: (1) cultural context, social determinants of health and access to care; (2) clinical and teaching skills and neurologic medical knowledge; (3) team-based practice; (4) developing global neurology partnerships; (5) ethics; (6) approach to clinical care; (7) community neurologic health; (8) health care systems and multinational health care organizations. DISCUSSION: These proposed competencies can serve as a foundation on which future global neurology training programs can be built and trainees evaluated. It may also serve as a model for global health training programs in other medical specialties as well as a framework to expand the number of neurologists from HICs trained in global neurology.