Antiplatelets Are Enough for Nondisabling Strokes.

This Viewpoint argues, in keeping with current stroke management guidelines, that patients with mild, nondisabling strokes should not receive thrombolysis, even when presenting within the time window for treatment.

Clinical Characteristics, Imaging Findings, and Outcomes of Cerebral Air Embolism.

BACKGROUND: Arterial cerebral air embolism (CAE) is an uncommon but potentially catastrophic event. Patients can present with focal neurologic deficits, seizures, or coma. They may be treated with hyperbaric oxygen therapy. We review the causes, radiographic and clinical characteristics, and outcomes of patients with CAE. METHODS: We performed a retrospective chart review via an existing institutional database at Mayo Clinic to identify patients with arterial CAE. Demographic data, clinical characteristics, and diagnostic studies were extracted and classified on predefined criteria of diagnostic confidence, and descriptive and univariate analysis was completed. RESULTS: Fifteen patients met criteria for inclusion in our study. Most presented with focal deficits (80%) and/or coma (53%). Seven patients (47%) had seizures, including status epilepticus in one (7%). Five presented with increased muscle tone at the time of the event (33%). Computed tomography (CT) imaging was insensitive for the detection of CAE, only identifying free air in 4 of 13 who underwent this study. When obtained, magnetic resonance imaging typically showed multifocal areas of restricted diffusion. Six patients (40%) were treated with hyperbaric oxygen therapy. Age, Glasgow Coma Scale score at nadir, and use of hyperbaric oxygen therapy were not associated with functional outcome at 1 year in our cohort. Twenty-six percent of patients had a modified Rankin scale score of 0 one year after the event, and functional improvement over time was common after discharge. CONCLUSIONS: A high index of clinical suspicion is needed to identify patients with CAE because of low sensitivity of free air on CT imaging and nonspecific clinical presentation. Acute alteration of consciousness, seizures, and focal signs occur frequently. Because improvement over time is possible even among patients with severe presentation, early prognostication should be approached with caution.

Etiologies and Utility of Diagnostic Tests in Trigeminal Neuropathy.

OBJECTIVE: To evaluate the utility of diagnostic studies in identifying treatable etiologies of trigeminal neuropathy (TNP). PATIENTS AND METHODS: We performed a review of consecutive patients with nontraumatic, noniatrogenic TNP seen at Mayo Clinic between January 1, 2000, and August 31, 2019. Patients were excluded if they had trigeminal neuralgia without neuropathy or if their diagnostic work-up had been completed elsewhere. Data were analyzed to determine which diagnostic studies were most useful in identifying treatable etiologies. RESULTS: In total, 439 patients were included. The mean ± SD age was 56.3±13.6 years and 285 (64.9%) were female. Among the 180 cases in which an etiology was identified (41.0%), neoplasms were causative in 76 (42.2%), while specific connective tissue diseases were implicated in 71 (39.4%). Bilateral TNP (n=83) was associated with the presence of underlying connective tissue disease (P<.01). Identification of etiology was made by magnetic resonance imaging in 88 cases (48.8%), by abnormal connective tissue disease cascades combined with rheumatology consultation in 42 (23.3%), by a previously known connective tissue disorder in 30 (16.7%), and by abnormal connective tissue disease cascades alone in 8 (4.4%). Among the 439 study patients, electromyography was performed in 211 (48.1%) and lumbar puncture in 139 (31.7%), but their diagnostic utility was low. CONCLUSION: Underlying causes of nontraumatic, noniatrogenic TNP can be identified in approximately 40% of cases. Bilateral TNP is strongly associated with underlying connective tissue disease. Careful history taking, dedicated magnetic resonance imaging, and connective tissue panels have the greatest diagnostic utility. Electromyography and cerebrospinal fluid analysis are unlikely to elucidate treatable etiologies of TNP.

A Case Report of "Propofol Frenzy": Anesthetic Considerations for a Severe Propofol-Induced Neuroexcitation Reaction.

Propofol "frenzy" is considered a severe propofol-induced neuroexcitatory reaction involving nonepileptic spells of extremity thrashing, marked agitation, irregular eye movements, and impaired consciousness. Patients with propofol neuroexcitation present unique challenges for anesthesia providers due to underrecognition, lack of diagnostic tests, and differentiating from other comparable disorders that require medications that can exacerbate symptoms. We present a case of a healthy young patient whose postoperative course was complicated by propofol frenzy and functional limb paralysis following hip surgery with a spinal anesthetic and propofol sedation. This case highlights anesthesia considerations for propofol frenzy and discusses dexmedetomidine as a promising modality for prompt management.

Subarachnoid hemorrhage from sudden gravitational changes.

Diffuse subarachnoid hemorrhage is commonly attributed to the rupture of intracranial aneurysms or other vascular malformations. Non-aneurysmal hemorrhages often have a characteristic pattern or clear mechanism (e.g. trauma) with an often more benign clinical course. We report the case of a diffuse non-aneurysmal subarachnoid hemorrhage due to sudden gravitational changes encountered during complex airflight maneuvers, complicated by hydrocephalus and cerebral vasospasm. This case illustrates a rare phenomenon that may again be encountered in the future with the advent and advancement of civilian spaceflight.

A Disclosure About Death Disclosure: Variability in Circulatory Death Determination.

INTRODUCTION: Circulatory-respiratory death declaration is a common duty of physicians, but little is known about the amount of education and physician practice patterns in completing this examination. METHODS: An online survey of physicians was conducted evaluating the rate of formal training and specific examination techniques used in the pronouncement of circulatory-respiratory death. Data, including the level of practice, training received in a formal death declaration, and examination components, were collected. RESULTS: Respondents were attending physicians (52.4%), residents (30.2%), fellows (10.7%), and interns (6.7%). Most respondents indicated they had received no formal training in death pronouncement; however, most reported self-perceived competence. When comparing examination components used by the study's cohort, 95 different examination combinations were used for death pronouncement. CONCLUSIONS: Formal training in death pronouncement was uncommon and clinical practice varied. Implementation of formal training and standardization of the examination are necessary to improve physician competence and reliability in death declarations.

Use of diffusion-weighted imaging to distinguish seizure-related change from limbic encephalitis.

OBJECTIVE: To determine whether diffusion-weighted imaging (DWI) can help differentiate peri-ictal signal abnormality from limbic encephalitis (LE) among patients with medial temporal lobe T2-hyperintensity. METHODS: We retrospectively identified patients with peri-ictal medial temporal lobe T2-hyperintensity using a Mayo Clinic database, and reviewed their DWI to look for unique diffusion restriction patterns. We then identified patients with medial temporal lobe T2-hyperintensity and LE, and reviewed their DWI to see if these patterns were ever present. Presence of diffusion restriction patterns was confirmed by a blinded neuro-radiologist. RESULTS: We identified 10 patients without LE who had peri-ictal unilateral medial temporal lobe T2-hyperintensity, ipsilateral to focal seizure onset. Nine of 10 (90%) had at least one of two diffusion restriction patterns potentially unique to seizure activity; four had gyriform hippocampal diffusion restriction ("Pattern 1"), three had diffuse hippocampal diffusion restriction that spared the most medial temporal lobe structures ("Pattern 2"), and two had both diffusion restriction patterns. The median patient age was 62 years (range 2-76 years) and 3/9 (33%) were female. In comparison, among patients with medial temporal lobe T2-hyperintensity and LE, only 5/57 (9%) had one of the diffusion restriction patterns ("Pattern 2") identified (P < 0.0001); all five had seizures reported. CONCLUSIONS: In patients with medial temporal lobe T2-hyperintensity and one of the diffusion restriction patterns described herein, the signal abnormality may be a peri-ictal phenomenon rather than indicative of LE and should prompt investigation for seizure. Even in patients with LE, these patterns should raise concern for seizure.

Evaluator Agreement in Medical Student Assessment Across a Multi-Campus Medical School During a Standardized Patient Encounter.

PURPOSE: Class rank and clerkship grades impact a medical student's residency application. The variability and inter-rater reliability in assessment across multiple clinical sites within a single university system is unknown. We aimed to determine if medical student assessment across medical school campuses is consistent when using a standardized scoring rubric. DESIGN/METHODS: Attending physicians who participate in assignment of clerkship grades for neurology from three separate clinical campuses of the same medical school observed 10 identical standardized patient encounters completed by third year medical students during the 2017-2018 academic year. Scoring was completed using a standardized rubric. Descriptive analysis and intra-rater comparisons were completed. Evaluations as a part of this study were completed in 2018. RESULTS: Of 50 possible points for the patient encounter, the median score among all medical students and all evaluators was 43 (IQR 40, 45.5). Evaluator number 1 provided a statistically significant lower overall score as compared to evaluators 2 and 3 (p = 0.0001 and p = 0.0006, respectively), who were consistently similar in their overall medical student assessment (p = 0.46). Overall agreement between evaluators was good (ICC = 0.805, 95% CI 0.36-0.95) and consistency was excellent (ICC = 0.91, 95% CI 0.75-0.97). CONCLUSIONS: Medical student evaluation across multiple clinical campus sites via observation of identical standardized patient encounters and use of a standardized scoring rubric generally demonstrated good inter-rater agreement and consistency, but the small variation seen may affect overall clerkship scores.

Can we stop the stuttering in stroke? Interventions in 40 patients with acute lacunes.

BACKGROUND: Whether any treatment can stop fluctuations of stuttering lacunar syndromes (SLS) is unclear. Case reports have variably suggested effectiveness of intravenous thrombolysis, dual antiplatelet treatment, blood pressure augmentation and anticoagulation. We aim to describe our experience with different treatments used in in patients presenting with SLS and their effect on clinical fluctuations and functional outcome. METHODS: We collected demographic and clinical data of consecutive adult patients with SLS. Descriptive summaries were reported as median and inter-quartile range (IQR) for continuous variables and as frequencies and percentages for categorical variables. RESULTS: Forty patients (72 ±â€¯10 years, 36% female) were included. Pure motor syndrome (57%) was the most frequent clinical presentation. Clinical fluctuations stopped and the improvement was temporally related to aspirin-clopidogrel in 11/17 cases, intravenous thrombolysis in 4/6 cases, blood pressure augmentation in 1/3 cases and aspirin in 1/7 cases. Two patients continued fluctuating after IVT and later responded to blood pressure augmentation (n = 1) or aspirin-clopidogrel (n = 1). CONCLUSIONS: Aspirin plus clopidogrel may be followed by clinical improvement when intravenous thrombolysis is not an option. Blood pressure augmentation may beneficial as ad-on treatment in patients with labile blood pressure.

Variability in reported physician practices for brain death determination.

OBJECTIVES: The degree of training and variability in the clinical brain death examination performed by physicians is not known. METHODS: Surveys were distributed to physicians (including physicians-in-training) practicing at 3 separate academic medical centers. Data, including level of practice, training received in completion of a brain death examination, examination components performed, and use of confirmatory tests were collected. Data were evaluated for accuracy in the brain death examination, self-perceived competence in the examination, and indications for confirmatory tests. RESULTS: Of 225 total respondents, 68 reported completing brain death examinations in practice. Most physicians who complete a brain death examination reported they had received training in how to complete the examination (76.1%). Seventeen respondents (25%) reported doing a brain death examination that is consistent with the current practice guideline. As a part of their brain death assessment, 10.3% of physicians did not report completing an apnea test. Of clinicians who obtain confirmatory tests on an as-needed basis, 28.3% do so if a patient breathes during an apnea test, a clinical finding that is not consistent with brain death. CONCLUSIONS: There is substantial variability in how physicians approach the adult brain death examination, but our survey also identified lack of training in nearly 1 in 4 academic physicians. A formal training course in the principles and proper technique of the brain death examination by physicians with expert knowledge of this clinical assessment is recommended.

Application of the FOUR Score in Intracerebral Hemorrhage Risk Analysis.

BACKGROUND: The Full Outline of Unresponsiveness (FOUR) Score is a validated scale describing the essentials of a coma examination, including motor response, eye opening and eye movements, brainstem reflexes, and respiratory pattern. We incorporated the FOUR Score into the existing ICH Score and evaluated its accuracy of risk assessment in spontaneous intracerebral hemorrhage (ICH). MATERIALS AND METHODS: Consecutive patients admitted to our institution from 2009 to 2012 with spontaneous ICH were reviewed. The ICH Score was calculated using patient age, hemorrhage location, hemorrhage volume, evidence of intraventricular extension, and Glasgow Coma Scale (GCS). The FOUR Score was then incorporated into the ICH Score as a substitute for the GCS (ICH ScoreFS). The ability of the 2 scores to predict mortality at 1 month was then compared. RESULTS: In total, 274 patients met the inclusion criteria. The median age was 73 years (interquartile range 60-82) and 138 (50.4%) were male. Overall mortality at 1 month was 28.8% (n = 79). The area under the receiver operating characteristic curve was .91 for the ICH Score and .89 for the ICH ScoreFS. For ICH Scores of 1, 2, 3, 4, and 5, 1-month mortality was 4.2%, 29.9%, 62.5%, 95.0%, and 100%. In the ICH ScoreFS model, mortality was 10.7%, 26.5%, 64.5%, 88.9%, and 100% for scores of 1, 2, 3, 4, and 5, respectively. CONCLUSIONS: The ICH Score and the ICH ScoreFS predict 1-month mortality with comparable accuracy. As the FOUR Score provides additional clinical information regarding patient status, it may be a reasonable substitute for the GCS into the ICH Score.

Ventriculostomy and Risk of Upward Herniation in Patients with Obstructive Hydrocephalus from Posterior Fossa Mass Lesions.

BACKGROUND: Patients with posterior fossa lesions causing obstructive hydrocephalus present a unique clinical challenge, as relief of hydrocephalus can improve symptoms, but the perceived risk of upward herniation must also be weighed against the risk of worsening or continued hydrocephalus and its consequences. The aim of our study was to evaluate for clinically relevant upward herniation following external ventricular drainage (EVD) in patients with obstructive hydrocephalus due to posterior fossa lesions. METHODS: We performed a retrospective review of patients undergoing urgent/emergent EVD placement at our institution between 2007 and 2014, evaluating the radiographic and clinical changes following treatment of obstructive hydrocephalus. RESULTS: Even prior to EVD placement, radiographic upward herniation was present in 22 of 25 (88%) patients. The average Glasgow Coma Scale of patients before and after EVD placement was 10 and 11, respectively. Radiographic worsening of upward herniation occurred in two patients, and upward herniation in general persisted in 21 patients. Clinical worsening occurred in two patients (8%), though in all others the clinical examination remained stable (44%) or improved (48%) following EVD placement. Of the patients who had a worsening clinical exam, other variables likely also contributed to their decline, and cerebrospinal fluid diversion was likely not the main factor that prompted the clinical change. CONCLUSIONS: Radiographic presence of upward herniation was often present prior to EVD placement. Clinically relevant upward herniation was rare, with only two patients worsening after the procedure, in the presence of other clinical confounders that likely contributed as well.