Neurocysticercosis in non-endemic regions: The experience of Qatar.

Objective: To describe the occurrence and features of Neurocystircercosis (NCC) in Qatar. Background: Qatar has a mixed population of natives and expats. NCC is not endemic to the region, but clinical practice suggests its occurrence in large numbers. Design/ methods: A database was created to summarize information retrospectively collected on patients with NCC seen through the national health system (HMC) between 2013 and 2018. We identified demographic and disease related variables (clinical manifestations, investigative findings, treatment and outcome) for all patients. Results: Out of 420 identified NCC patients, 393 (93.6%) were men, and 98.3% were immigrants from NCC endemic countries such as Nepal (63.8%) and India (29.5%). Eighty percent of patients presented with seizures, with the majority (69%) experiencing generalized tonic-clonic seizures. Five percent presented with status epilepticus. Headaches, the second most common complaint, were reported in 18% of subjects. On imaging, 50% had a single lesion while 63% included pathology at the calcified stage. The lesions were parenchymal in 99.5% of cases, predominantly in the frontal lobe (59%). Thirteen percent were diagnosed incidentally on imaging, mainly in the form of isolated calcified non enhancing lesions. Albendazole was received by 55% of patients, and phenytoin was the most prescribed anti-seizure drug (57%). When long term follow up was available, 70% of the patients presenting with seizures were completely seizure free. Conclusion: NCC is prevalent in Qatar, mainly within the large Southeast Asian immigrant population. NCC is currently a significant contributor to the epilepsy burden in Qatar, often with a good outcome regarding seizure control. NCC with intraparenchymal single lesion shares a large proportion of our cohort.

Multimodal Prediction of Favorable Outcome After Cardiac Arrest: A Cohort Study.

OBJECTIVES: Prognostic guidelines after cardiac arrest (CA) focus on unfavorable outcome prediction; favorable outcome prognostication received less attention. Our aim was to identify favorable outcome predictors and combine them into a multimodal model. DESIGN: Retrospective analysis of prospectively collected data (January 2016 to June 2021). SETTING: Two academic hospitals (Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Brigham and Women's Hospital, Boston, MA). PATIENTS: Four hundred ninety-nine consecutive comatose adults admitted after CA. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: CA variables (initial rhythm, time to return of spontaneous circulation), clinical examination (Full Outline of UnResponsiveness [FOUR] score at 72 hr, early myoclonus), electroencephalography (EEG) (reactivity, continuity, epileptiform features, and prespecified highly malignant patterns), somatosensory-evoked potentials, quantified pupillometry, and serum neuron-specific enolase (NSE) were retrieved. Neurologic outcome was assessed at 3 months using Cerebral Performance Category (CPC); 1 and 2 were considered as favorable outcome. Predictive performance of each variable toward favorable outcomes were calculated, and most discriminant items were combined to obtain a multimodal prognostic score, using multivariable ordinal logistic regression, receiving operator characteristic curves, and cross-validation. Our analysis identified a prognostic score including six modalities (1 point each): 1) early (12-36 hr) EEG not highly malignant, 2) early EEG background reactivity, 3) late (36-72 hr) EEG background reactivity and 4) continuity, 5) peak serum NSE within 48 hours less than or equal to 41 µg/L, and 6) FOUR score greater than or equal to 5 at 72 hours. At greater than or equal to 4 out of 6 points, sensitivity for CPC 1-2 was 97.5% (95% CI, 92.9-99.5%) and accuracy was 77.5% (95% CI, 72.7-81.8%); area under the curve was 0.88 (95% CI, 0.85-0.91). The score showed similar performances in the validation cohort. CONCLUSIONS: This study describes and externally validates a multimodal score, including clinical, EEG and biological items available within 72 hours, showing a high performance in identifying early comatose CA survivors who will reach functional independence at 3 months.

CD8 Encephalitis: A Diagnostic Dilemma.

CD8+ encephalitis is a subacute encephalopathy associated with HIV infection. Pathophysiology is thought to be auto-reactive CD8+ cells attacking on HIV infected CD4+ cells and 'viral escape' phenomena (replication of CD8+ cells in CSF). We present a case of a 45-year-old man with well controlled HIV who developed CD8 encephalitis following Herpes simplex encephalitis. He had persistent encephalopathy for several weeks with status epilepticus and agitated delirium, and diagnosis remained elusive until a brain biopsy confirmed the diagnosis.

Predictors of No-Show in Neurology Clinics.

In this study, we aim to identify predictors of a no-show in neurology clinics at our institution. We conducted a retrospective review of neurology clinics from July 2013 through September 2018. We compared odds ratio of patients who missed appointments (no-show) to those who were present at appointments (show) in terms of age, lead-time, subspecialty, race, gender, quarter of the year, insurance type, and distance from hospital. There were 60,012 (84%) show and 11,166 (16%) no-show patients. With each day increase in lead time, odds of no-show increased by a factor of 1.0019 (p < 0.0001). Odds of no-show were higher in younger (p ≤ 0.0001, OR = 0.49) compared to older (age ≥ 60) patients and in women (p < 0.001, OR = 1.1352) compared to men. They were higher in Black/African American (p < 0.0001, OR = 1.4712) and lower in Asian (p = 0.03, OR = 0.6871) and American Indian/Alaskan Native (p = 0.055, OR = 0.6318) as compared to White/Caucasian. Patients with Medicare (p < 0.0001, OR = 1.5127) and Medicaid (p < 0.0001, OR = 1.3354) had higher odds of no-show compared to other insurance. Young age, female, Black/African American, long lead time to clinic appointments, Medicaid/Medicare insurance, and certain subspecialties (resident and stroke clinics) are associated with high odds of no show. Possible suggested interventions include better communication and flexible appointments for the high-risk groups as well as utilizing telemedicine.

Autoimmune encephalitis and seizures, cerebrospinal fluid, imaging, and EEG findings: a case series.

Antibody-mediated encephalitides constitute a group of inflammatory brain diseases characterized by prominent neuropsychiatric symptoms and are associated with antibodies against neuronal cell-surface proteins, ion channels, or receptors. The diagnosis and management of autoimmune encephalitis include evaluation of the clinical presentation, brain imaging, cerebrospinal fluid (CSF) findings, antibody detection, and electroencephalography (EEG) findings. This is a retrospective study of adults 18 years or older with autoimmune encephalitis due to antibodies against membrane surface antigens as well as anti-glutamic acid decarboxylase (anti-GAD) antibodies. The electronic medical record was reviewed for demographic data, clinical data, laboratory results, EEG, and imaging findings. Antibody screening was requested for 341 patients between May 2014 and December 2019. Antibody screening was positive in 37 patients presenting with seizures and/or encephalopathy. Of these, 10 patients tested positive for antibodies against neuronal surface antigens or anti-GAD antibodies-2 patients had anti-GAD antibody encephalitis, 5 had anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, and 3 had anti-leucine-rich glioma-inactivated 1 (anti-LGI1) encephalitis. Demographics, clinical presentation, EEG, imaging, and CSF findings are reported. Autoimmune encephalitides are a diverse group of disorders with a few common clinical features and MRI findings. MRI, EEG, and CSF findings can be normal or show nonspecific findings in autoimmune encephalitis. Therefore, early diagnosis of these disorders requires a high level of suspicion to avoid delaying the diagnosis. Carefully looking for diagnostic clinical features (e.g., faciobrachial dystonic seizures in anti-LGI1 encephalitis), significant findings in MRI (e.g., limbic encephalitis), and some EEG patterns (e.g., extreme delta brush and generalized rhythmic delta activity in anti-NMDAR encephalitis) may help in early diagnosis.

Cost-Effectiveness of Emergent MRI during Stroke Alert to Diagnose Stroke Mimics: Single-Center Experience.

Objective The aim of this article was to assess the role of emergent magnetic resonance imaging (MRI) for stroke mimics during a stoke alert (within 45 minutes) in reducing direct cost of management and duration of inpatient stay. Methods We did a retrospective chart review of all the patients who received emergent MRI brain during a stroke alert to help make decision about intravenous tissue-type plasminogen activator (IV tPA) administration from January 2013 to December 2015. Using the patient financial resource data and with the help of billing department, we calculated the approximate money saved in taking care of the patients who may have received IV tPA if emergent MRI brain was not available to diagnose stroke mimics as they presented with acute neurologic deficit within IV tPA time window. Results Ninety seven out of 1,104 stroke alert patients received emergent MRI. Of these only 17 (17.5%) were diagnosed with acute ischemic stroke (AIS), and 80 (82.5%) as stroke mimics. By doing emergent MRI for suspected stroke mimics, our study showed an approximate total saving of $1,005,720 to $1,384,560, that is, $12,571 to $17,307 per patient in medical expenditure. Discussion We suggest modification of stroke pathway from current algorithm "CT+CTA≥IV-tPA/neurointervention≥MRI" to "MRI+MRA≥IV-tPA/neurointervention" for possible stroke mimics, which can reduce the cost, radiation exposure, and duration of hospital stay for stroke mimics. Conclusion Emergent MRI is a cost-effective tool to evaluate IV-tPA eligibility for suspected stroke mimics during a stroke alert.

Stroke transfers for thrombectomy in the era of extended time.

BACKGROUND AND PURPOSE: The Dawn and Extend Intra-Arterial (IA) acute stroke intervention trials have proven the benefit of thrombectomy in a select group of patients up to 24 h since their last known well time (LKWT) or time of symptom onset. Following the issuance of new treatment guidelines for large vessel occlusion strokes, we reviewed the paradigm shift effect on transfers for possible thrombectomy in a rural state. HYPOTHESIS: Extended time window for thrombectomy increases the need for better identification of potential transfers for thrombectomy in rural states with few hospitals capable of 24/7 interventional thrombectomy. METHODS: We analyzed all transfers to a comprehensive stroke center (CSC) from January to December 2018 which were specifically transferred for possible further intervention. This time period was selected in accordance with the change in American Heart Association (AHA) guidelines for extended time windows in mechanical thrombectomy (MT) care. RESULTS: A total of 132 patients were transferred for possible thrombectomy and advanced imaging. Thirty-four % patients underwent diagnostic angiogram with 33% patients having successful MT. Of the excluded patients 19% had large core infarcts by the time they arrived at hub hospital, 1.5% had hemorrhagic conversion, 32% had stroke without treatable occlusion not amenable for thrombectomy or cortical strokes on follow-up imaging, and 13.5% did not have stroke or LVO on follow-up imaging. CONCLUSION: Since the AHA's change in time window guidelines for mechanical thrombectomies, there has been an increased effort in identifying good candidates with computerized tomography angiography (CTA). To avoid undue burden on stroke systems of care, CTA identification of these patients at the spoke hospitals is key along with timely transport to appropriate thrombectomy capable sites. Given the rural nature of this state along with limited resources, selection of patients is a practical issue, especially for avoiding futile transfers, which might be true for large areas of the USA.

COVID-19 and stroke, a case series and review of literature.

BACKGROUND: Corona Virus Disease 2019 (COVID-19) cases continue to increase around the World. Typical symptoms include fever and respiratory illness but a constellation of multisystem involvement including central nervous system (CNS) and peripheral nervous system (PNS) have been reported with COVID-19. Acute ischemic strokes (AIS) have also been reported as a complication. METHODOLOGY: We analyzed patient characteristics, clinical outcomes, laboratory results and imaging results of four patients with COVID-19 who had AIS. RESULTS: All four patients were =< 60 years, had hypoxemic respiratory failure secondary to pneumonia, elevated D-dimer and inflammatory markers. CONCLUSION: Ischemic strokes are known complications in patients with severe COVID-19.

Use of direct oral anticoagulants in cerebral venous thrombosis: a systematic review.

: We are here to review the efficacy and safety of direct oral anticoagulants (DOACs) in the treatment of Cerebral Venous Thrombosis (CVT). A search strategy was developed with a research librarian. All published articles including trials, studies, case series, and case reports were reviewed from NCBI/PubMed up to May 2019 by two independent reviewers. A total of 11 studies were identified, which included 70 patients with CVT on DOACs. After 6 months follow-up more than 86.7% of these patients had a good outcome on the Modified Rankin Scale (mRS) of 0--1 at 6 months and no recurrence of venous thromboembolic events (VTE) at 12 months. Recanalization rate at 6 months varied from 55 to 100%. Only two patients had a side effect of minor bleeding because of DOAC usage. Although the current American Heart Association/American Stroke Association and European Stroke Organization guidelines do not endorse the use of DOACs for treatment of CVT because of lack of evidence from large randomized clinical trials, Use of DOACs in CVT appears to be well tolerated and efficacious with favorable outcomes. Further evidence is needed to establish their use in CVT.

Stroke in the adult Qatari population (Q-stroke) a hospital-based retrospective cohort study.

BACKGROUND: Studies assessing the burden of stroke in Qataris are limited. We aim to study stroke in the Qatari population. METHODS: A retrospective review was undertaken of all Qatari adults presenting with stroke to Hamad Medical Corporation over a 5-year period. Descriptive statistics were used to summarize demographic and all other clinical characteristics of the patients. The primary outcome was the incidence of stroke in the Qatari patients. Comparison was made between the sexes. RESULTS: 862 patients were included, with 58.9% being male. The average incidence of stroke over the 5-year period was 92.04 per 100,000 adult Qatari population. The mean age of the cohort was 64.3±14.4 years, (range 19-105 years). The mean age of first ever cerebrovascular event was 63.2±14.5 years. The diagnosis was ischemic stroke in (73.7%), transient ischemic attack in (13.8%), intracerebral hemorrhage (ICH) in (11.6%), subarachnoid hemorrhage in (0.7%) and (0.2%) cerebral venous sinus thrombosis. Small vessel disease was the most common cause of ischemic stroke accounting for (46.5%), followed by large artery atherosclerosis (24.5%). Hypertension (82.7%) and diabetes (71.6%) were particularly prevalent in this cohort. Females were older (65.8±14.1 vs 63.4±14.5 years), had more hypertension and diabetes and more disability or death at 90 days (p<0.05) compared to Qatari males. CONCLUSION: Stroke occurs at a significantly lower age in Qataris compared to the western population. This study has uncovered sex differences that need to be studied further.

Progression of stroke deficits in patients presenting with mild symptoms: The underlying etiology determines outcome.

BACKGROUND AND PURPOSE: Patients with acute stroke and mild or rapidly improving symptoms frequently show progression. The role of reperfusion treatment in such patients is not clear. We hypothesized that progression was most likely in patients with cortical localization and such patients may benefit from thrombolysis. MATERIAL AND METHODS: We interrogated Hamad Stroke Database to evaluate 90-days outcome in patients with acute ischemic stroke admitted within 4 hours and a NIHSS score of ≤6. Evaluation was based on localization (lacunar or cortical), multi-model imaging abnormalities and whether they received rt-PA. The 90-day mRS was used to determine outcome. RESULTS: During study period 6381 patients were admitted with acute stroke. Mild stroke within 4 hours was diagnosed in 506 [no thrombolysis: 381(lacunar: 213; cortical: 168), thrombolysis: 125 (lacunar: 45; cortical: 80)]. The rt-PA treated patients had significantly higher NIHSS (2.94±3.9 versus 1.28±2.46, p<0.0001), increased rates of complications (16.0% versus 3.9%, p<0.0001) and longer hospital stay (6.05±8.1 versus 3.78±3.6 days; p<0.001). In patients with cortical stroke, intracranial arterial occlusions (11.6% vs 3.9%, p<0.0001) and CTP mismatch (22.2% vs 4.4%, p<0.0001) were more frequent in rt-PA treated patients. Discharge mRS (33.6% versus 13.9%, p<0.001) and 90-days mRS (23.2% versus 11.8%, p = 0.002) was significantly worse in patients with cortical stroke (rt-PA-treated and untreated patients). CONCLUSIONS: The outcome in patients with mild stroke depends on lesion location (lacunar versus cortical) and severity of symptoms. Patients who receive rt-PA have significantly larger deficits, increased imaging abnormalities and higher rates of hospital complication, explaining the poor outcome in such subjects.

Metastatic hepatocellular carcinoma to parotid glands.

PATIENT: Male, 66. FINAL DIAGNOSIS: Hepatocellular carcinoma. SYMPTOMS: Abdominal distension • painful right facial swelling • weight loss. MEDICATION: -. CLINICAL PROCEDURE: -. SPECIALTY: -. OBJECTIVE: Rare disease. BACKGROUND: Hepatocellular carcinoma is a common cancer, but it rarely metastasizes to the salivary glands. A review of the literature revealed only 5 reported cases of hepatocellular carcinoma metastatic to parotid glands. We here report an additional case of this rare association. CASE REPORT: A 66-year-old male with a background of type 2 diabetes mellitus and post-alcoholic decompensated liver cirrhosis presented with a progressively enlarging painful right facial swelling for 2 months that was eventually found to be due to hepatocellular carcinoma metastatic to the right parotid gland. Fine needle aspiration from the right parotid showed sheets and single malignant cells that were interpreted as carcinoma not otherwise specific. However, biopsy showed metastatic hepatocellular carcinoma into the right parotid gland. CONCLUSIONS: We report an additional case of the rare metastasis of hepatocellular carcinoma to the parotid glands. It should therefore be considered in a patient with decompensated liver cirrhosis presenting with a parotid swelling. Furthermore, the present case demonstrates the importance of the tissue biopsy for obtaining an accurate final diagnosis.

Management of acute diverticulitis in the East Anglian region: results of a United Kingdom regional survey.

PURPOSE: Acute diverticulitis is the most common presentation of diverticular disease; however, no published guidelines for management are available in the United Kingdom. This survey was designed to assess the current United Kingdom regional practice compared with the guidelines published by The American Society of Colon and Rectal Surgeons. METHODS: A questionnaire survey focused on the management of acute diverticulitis was sent to all consultants, specialist registrars, and staff-grade surgeons in general surgery in one United Kingdom region. RESULTS: Eighty-two questionnaires were returned (80 percent). A majority (80 percent) would request routine blood tests, abdominal, and erect chest x-rays on arrival. Pethidine (56 percent) was the preferred analgesic, followed by morphine (40 percent). Ninety-four percent used an antibiotic combination of second/third-generation cephalosporin and metronidazole. Computerized tomography was the most commonly used initial investigation (42 percent). Forty percent use barium enema and 31 percent use a combination of barium enema and sigmoidoscopy as follow-up investigations. In patients older than aged 50 years, elective resection would be considered by a majority (51 percent) only when complications arose. In those aged 50 years or younger, 35 percent would resect only if complications arose with only 6 percent after a single episode of acute diverticulitis. CONCLUSIONS: There are major differences in the management of patients with acute diverticulitis in our current practice in one United Kingdom region compared with the guidelines published by The American Society of Colon and Rectal Surgeons, which are based on published literature. There is an urgent need to establish similar guidelines in the United Kingdom to improve the clinical outcome of patients with such a common condition.