Tofacitinib-induced Progressive Multifocal Leukoencephalopathy with Immune Reconstitution Inflammatory Syndrome.

BACKGROUND: Progressive multifocal leukoencephalopathy (PML) with subsequent immune reconstitution inflammatory syndrome (IRIS) is a rare disease associated with compromised immune systems. It has never been described in a patient taking tofacitinib. CASE PRESENTATION: A 49-year-old woman with history of systemic lupus erythematous treated with tofacitinib presented with several weeks of intermittent fevers and altered mental status. MRI revealed multifocal T2-weighted FLAIR hyperintensities in the subcortical white matter, including the subcortical U-fibers, without mass effect or contrast enhancement, compatible with PML. Tofacitinib was stopped and the patient's symptoms initially improved. However, the patient presented again less than a week after discharge with three days of left arm weakness, left facial droop, dysarthria, and one day of confusion. Repeat MRI demonstrated interval progression in T2/FLAIR hyperintensities with development of patchy gadolinium enhancement on T1-post contrasted sequences, consistent with development of IRIS in the setting of tofacitinib cessation. DISCUSSION: This is the first case describing PML-IRIS in the setting of administration and subsequent cessation of tofacitinib.

Neurology Journal Club: Hypertensive Disorders of Pregnancy and Cognitive Impairment: A Prospective Cohort Study.

Women with gestational hypertension and preeclampsia, termed hypertensive disorders of pregnancy (HDP), are at risk of developing cardiovascular disease and potentially cognitive impairment years after pregnancy. In their study, Adank et al. hypothesized that patients with HDP might have worse cognitive performance compared with women with previous normotensive pregnancies and sought to evaluate long-term cognitive performance in these 2 populations. In this Journal Club article, we aim to review key study findings and discuss potential shortcomings and future directions.

Cervical Carotid Stent Collapse During Balloon Guide Catheter Aspiration.

Balloon guide catheters (BGCs) can be used during cervical carotid stenting as a proximal protection strategy to minimize thromboembolic procedural complications (Video 1). A 9-French BGC can be swiftly inflated before each embologenic step of carotid stenting (microwire crossing, prestent angioplasty, stenting, poststent angioplasty); aspirated; and deflated. We present 2 unique cases in which the impact of BGC aspiration is demonstrated on cervical carotid stenting for atherosclerotic stenoocclusive disease. On deflation of the poststent angioplasty balloon with concomitant aspiration of the BGC through a 60-mL vacuum syringe, stent collapse was noted. Stent self-reexpansion was documented after reversal of negative pressure from the vacuum syringe, allowing for gentler aspiration. Awareness and early recognition of this potential for vessel wall collapse with aspiration are important to prevent vessel/stent collapse, inefficient aspiration, and resultant embolization of debris. Gradual aspiration is favored.

Carotid Web Phenotype Is Uncommonly Associated With Classic Fibromuscular Dysplasia: A Retrospective Observational Study.

BACKGROUND AND PURPOSE: Carotid web (CaW) is an intimal form of fibromuscular dysplasia (FMD) involving the carotid bulb which has been increasingly recognized as a potential cause of recurrent ischemic strokes. It is overlooked as a separate entity and often dismissed if no coexistent signs of classic FMD changes are observed. We aim to evaluate the frequency of classic FMD in high-yield vascular territories in patients with symptomatic CaW. METHODS: This was a retrospective analysis of a symptomatic CaW database of 2 comprehensive stroke centers (spanning September 2014-October 2020). The diagnosis of a CaW during a stroke workup was defined as the presence of a shelf-like linear filling defect in the posterior aspect of the carotid bulb on computed tomography angiography in patients with acute ischemic stroke or transient ischemic attack of undetermined cause after a thorough evaluation. Neck computed tomography angiography and renal conventional angiography images were independently evaluated by two readers blinded to the laterality and clinical details to inspect the presence of underlying classic FMD. RESULTS: Sixty-six patients with CaW were identified. Median age was 51 years (interquartile range, 42-57), and 74% were women. All patients had neck computed tomography angiography (allowing for bilateral vertebral and carotid evaluation), whereas 47 patients had additional digital subtraction angiography (which evaluated 47 carotids ipsilateral to the stroke and 10 contralateral carotids). Internal carotid artery classic FMD changes were noted in only 6 out of 66 (9%) in the ipsilateral carotids. No contralateral carotid or vertebral artery classic FMD changes were observed. Renal artery catheter-based angiography was obtained in 16 patients/32 arteries and only 1 patient/2 renal arteries demonstrated classic FMD changes. CONCLUSIONS: CaW phenotype is uncommonly associated with classic FMD changes. Coexistent classic FMD does not constitute a useful marker to corroborate or exclude CaW diagnosis.

Breast Reconstruction and Radiation Therapy.

PURPOSE: The optimal approach to the integration of postmastectomy reconstruction and radiation therapy is not well-established. This review will summarize current literature pertaining to the most common types of reconstruction in the setting of postmastectomy radiation therapy (PMRT). DATA SOURCES: Literature from PubMed was reviewed from 2000 to 2016. STUDY SELECTION: Studies were selected with relevance to "postmastectomy breast reconstruction," "breast reconstruction," and "breast reconstructive methods and PMRT." Surgical outcomes, patient satisfaction, and cost-effectiveness were examined. DATA EXTRACTION: Data from publications was extracted, summarized, and converted to a table. RESULTS OF DATA SYNTHESIS: Implant-based techniques are on the rise, in the setting of PMRT. Implant-based methods are more affordable in the short term and result in immediate breast-mound formation compared to autologous methods. When compared to implant-based reconstruction with PMRT, autologous reconstruction with PMRT results in better quality of life (QoL) and sensory recovery as well as fewer complications and failures. Among autologous flaps, deep inferior epigastric perforator flaps are considered superior to transverse rectus abdominal muscle (TRAM) pedicled flaps and may be more suitable for PMRT. Latissimus dorsi and muscle-sparing free TRAM flaps are also viable options. In delayed autologous, which may be advantageous for high-risk patients, the optimal timing to delay surgery after radiation therapy is unknown. Reconstruction with a 2-stage tissue expander-implant technique offers good to excellent cosmetic outcomes in the setting of PMRT, although there may be complications in this 2-stage process. CONCLUSION: Surgical, cosmetic, quality of life, and life expectancy must be taken into account when selecting the way to integrate breast reconstruction and PMRT.