Acute Caudate Nucleus Stroke Presenting As Hemiballismus.

Hemiballismus is defined as irregular, involuntary, large-amplitude flinging movements by the limbs, confined to one side of the body. Hemichorea refers to a state of excessive and irregularly timed, non-repetitive and randomly distributed, spontaneous, involuntary, and abrupt movements. It is widely believed that hemiballismus and chorea are suggestive of a lesion to the basal ganglia and subthalamic nucleus (STN). However, there are other etiologies that may influence the clinical presentation. Patients may present with certain common clinical features corresponding to the affected area of the brain. For example, infarctions of the motor cortex present with hemiplegia or paralysis of one side of the body. Similarly, infarctions involving the language areas of the brain present with aphasia and are detrimental to speech production or comprehension and the ability to read and write. Typically, acute-onset hemichorea is suggestive of a lesion in the STN. Herein, we present a rare case of acute hemiballismus and hemichorea following infarction of the left caudate nucleus, as determined by magnetic resonance imaging (MRI) and computerized tomography (CT) imaging modalities.

Single-Center Outcomes of WATCHMAN™ Implantation with Comparison to Oral Anticoagulant and Dual Antiplatelet Therapy.

Background The WATCHMAN™ device is a Food and Drug Administration (FDA)-approved device that reduces the risk of stroke from atrial fibrillation (AF) in those who have a contraindication to taking oral anticoagulation. A key aspect of this device implantation is the choice of medical therapy in the months after device implantation with Vitamin K antagonist oral anticoagulants (OAC) being the mainstay of therapy but dual antiplatelet therapy (DAPT) poses as a potential alternative to patients who have a contraindication to OAC use. Methods Our single-center study retroactively followed 150 patients post-WATCHMAN™ implantation and evaluated outcomes at 12 months post-implantation in two cohorts, those treated with OAC or DAPT. Our results were obtained via chart review of a single-center electronic medical records system. Results In our study, 67.33% of study patients were males and 49.33% were on OAC compared to 36.00% that were on DAPT. Ten patients were not able to undergo device implantation. With this analysis, we found similarly low rates of complications such as stroke and device-associated thrombosis (DAT) in both groups. Our DAPT cohort did have a higher number of gastrointestinal (GI) bleeding but this was not significant in our analysis. Discussion Our study compares to larger trials that show similar outcomes between OAC and DAPT post-implantation of the WATCHMAN™ device. The increased number of GI bleeding in our DAPT cohort could be the result of the underlying advanced age and comorbidity of that patient cohort. Conclusion Our results suggest that DAPT is a safe alternative to OAC for patients undergoing WATCHMAN™ implantation.

Derivation and validation of a predictive scale to expedite endovascular intervention for acute stroke patients with an intervenable vessel occlusion.

BACKGROUND: Early endovascular intervention team mobilization may reduce reperfusion times and improve clinical outcomes for patients with acute ischemic stroke (AIS) with a possible intervenable vessel occlusion (IVO). In an emergency department or mobile stroke unit, incorporating rapidly available non-contrast CT (NCCT) information with examination findings may improve the accuracy of arterial occlusion prediction scales. For this purpose, we developed a rapid and straightforward IVO predictive instrument-the T3AM2PA1 scale. METHODS: The T3AM2PA1 scale was retrospectively derived from our 'Get with the Guidelines' database. We included all patients with acute stroke alert between January 2017 and August 2018 with a National Institutes of Health Stroke Scale (NIHSS) score between 5 and 25 inclusive. Different pre-intervention variables were collected, including itemized NIHSS and NCCT information. The T3AM2PA1 scale was also compared with other commonly used scales and was validated in a separate sequential retrospective cohort of patients with a full range of NIHSS scores. RESULTS: 574 eligible patients from 2115 acute stroke alerts were identified. The scale was established with five items (CT hyperdense sign, parenchymal hypodensity, lateralizing hemiparesis, gaze deviation, and language disturbance), with a total score of 9. To minimize unnecessary angiography, a cut-off of ≥5 for IVO detection yielded a sensitivity of 52%, a specificity of 90%, and a positive predictive value of 76%. CONCLUSIONS: The T3AM2PA1 scale accurately predicts the presence of clinical IVO in patients with AIS. Adopting the T3AM2PA1 scale could reduce revascularization times, improve treatment outcomes, and potentially reduce disability.

The Effects of COVID-19 on Physicians' Perceived Ability to Provide Care for Patients With Type II Diabetes Mellitus.

Background and objective The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents multiple, diverse challenges to providing appropriate medical care, especially in terms of medication and treatment adherence for chronic diseases such as type 2 diabetes mellitus (T2DM). The COVID-19 pandemic has exacerbated these barriers by potentially forcing physicians to modify their treatment plans due to limitations on in-person visits and changes to patients' financial and social support systems. It remains uncertain whether physicians believe they can provide the same standard of care using telehealth technology or other means to their patients during the pandemic. The goal of this study was to explore physician perceptions about their ability to provide care to patients with T2DM during the COVID-19 pandemic. Methodology This cross-sectional study collected data between January 25, 2021, and February 2, 2021, using an anonymous, self-administered online survey involving DO and MD physicians including residents treating patients with T2DM. The survey was administered via REDCap and collected data on participant demographics, attitudes, perceptions, knowledge, and prior and current (COVID-19-era) experience with care for T2DM patients. Physicians registered with the Florida Department of Health with publicly available emails were invited to participate. Results The survey showed that during the COVID-19 pandemic, 57.9% of physicians (n=48) believed that their patients have a weaker social support system; 68.7% (n=57) modified their patient care plans due to patients' financial difficulties; 78.4% (n=65) believed a regular physical exam is necessary to properly treat patients; 48.2% (n=40) did not believe they had a more complete picture of the case with remote consultations; 47.0% (n=39) were not as satisfied with remote consultations as with face-to-face patient visits; 68.7% (n=57) believed telehealth is necessary to adequately treat patients; 38.5% (n=32) have been less likely to refer their patients to other providers or specialists; 45.8% (n=38) reported concerns over admitting their patients to the hospital for acute medical care; 61.5% (n=51) reported having more patients delay scheduling their routine follow-up care; 61.5% (n=51) believed their patients have been less compliant with the healthcare plans recommended to them. Conclusions The study showed that COVID-19 has significantly impacted physicians' perceptions and abilities to provide care for patients with T2DM. COVID-19 has negatively impacted several crucial aspects of diabetes management, including consistent in-person examinations, social support, and referral to other required services, which could result in long-term consequences for these patients. Furthermore, our study suggests that physicians may not be as satisfied with the care they are able to provide via remote consultations as they are with in-person visits, which has significant implications as we move toward a more telehealth-driven healthcare delivery system.

Comparison of Long-Term Outcomes and Associated Factors between Younger and Older Rural Ischemic Stroke Patients.

Introduction: The rise of ischemic stroke among young adults has stressed the need to understand their risk profiles and outcomes better. This study aimed to examine the five-year ischemic stroke recurrence and survival probability among young patients in rural Pennsylvania. Methods: This retrospective cohort study included first-time ischemic stroke patients from the Geisinger Health System between September 2003 and May 2014. The outcomes included all-cause mortality and ischemic stroke recurrence at five years. Kaplan-Meier estimator, cumulative incidence function, Cox proportional hazards model, and Cause-specific hazard model were used to examine the association of independent variables with the outcomes. Results: A total of 4459 first-time ischemic stroke patients were included in the study, with 664 (14.9%) patients in the 18−55 age group and 3795 (85.1%) patients in the >55 age group. In the 18−55 age group, the five-year survival probability was 87.2%, and the cumulative incidence of recurrence was 8%. Patients in the 18−55 age group had significantly lower hazard for all-cause mortality (HR = 0.37, 95% CI 0.29−0.46, p < 0.001), and non-significant hazard for five-year recurrence (HR = 0.81, 95% CI 0.58−1.12, p = 0.193) compared to the >55 age group. Chronic kidney disease was found to be associated with increased mortality in the 18−55 age group. Conclusion: In our rural population, younger ischemic stroke patients were at the same risk of long-term ischemic stroke recurrence as the older ischemic stroke patients. Identifying the factors and optimizing adequate long-term secondary prevention may reduce the risk of poor outcomes among younger ischemic stroke patients.