Early anticoagulation in patients with stroke and atrial fibrillation is associated with fewer ischaemic lesions at 1 month: the ATTUNE study.

BACKGROUND: The optimal time to commence anticoagulation in patients with atrial fibrillation (AF) after ischaemic stroke or transient ischaemic attack (TIA) is unclear, with guidelines differing in recommendations. A limitation of previous studies is the focus on clinically overt stroke, rather than radiologically obvious diffusion-weighted imaging ischaemic lesions. We aimed to quantify silent ischaemic lesions and haemorrhages on MRI at 1 month in patients commenced on early (<4 days) vs late (≥4 days) anticoagulation. We hypothesised that there would be fewer ischaemic lesions and more haemorrhages in the early anticoagulant group at 1-month MRI. METHODS: A prospective multicentre, observational cohort study was performed at 11 Australian stroke centres. Clinical and MRI data were collected at baseline and follow-up, with blinded imaging assessment performed by two authors. Timing of commencement of anticoagulation was at the discretion of the treating stroke physician. RESULTS: We recruited 276 patients of whom 208 met the eligibility criteria. The average age was 74.2 years (SD±10.63), and 79 (38%) patients were female. Median National Institute of Health Stroke Scale score was 5 (IQR 1-12). Median baseline ischaemic lesion volume was 5 mL (IQR 2-17). There were a greater number of new ischaemic lesions on follow-up MRI in patients commenced on anticoagulation ≥4 days after index event (17% vs 8%, p=0.04), but no difference in haemorrhage rates (22% vs 32%, p=0.10). Baseline ischaemic lesion volume of ≤5 mL was less likely to have a new haemorrhage at 1 month (p=0.02). There was no difference in haemorrhage rates in patients with an initial ischaemic lesion volume of >5 mL, regardless of anticoagulation timing. CONCLUSION: Commencing anticoagulation <4 days after stroke or TIA is associated with fewer ischaemic lesions at 1 month in AF patients. There is no increased rate of haemorrhage with early anticoagulation. These results suggest that early anticoagulation after mild-to-moderate acute ischaemic stroke associated with AF might be safe, but randomised controlled studies are needed to inform clinical practice.

Miller Fisher Syndrome Associated With Immunotherapy for Metastatic Melanoma.

Immunotherapy is a treatment strategy that has demonstrated survival benefit for metastatic melanoma. Ipilimumab and nivolumab are examples of immunotherapy, in which monoclonal antibodies antagonize cytotoxic T-lymphocyte-associated protein 4 and programmed death-ligand 1 receptors, respectively, resulting in upregulation of the host immune response to cancer cells. There is increasing recognition of immune-mediated adverse events associated with immune therapies in patients with cancer. We present a case report of a patient who developed Miller Fisher syndrome associated with these therapies for metastatic melanoma along with a discussion of its management.

Transient global amnesia: Diffusion MRI findings.

INTRODUCTION: Aim of this study is to identify and describe the MRI findings in patients with Transient Global Amnesia (TGA), specifically on Diffusion Weighted Imaging (DWI) sequence. METHODS: MRI findings in 12 patients with clinical diagnosis of TGA were retrospectively analysed. MRI brain was performed with a 3T scanner on 11 patients and 1.5T scanner on 1 patient. DWI were acquired at B value of 1000 s/mm2 in 4 patients, 2000 s/mm2 in 2 patients and both 1000 and 2000 s/mm2 in 6 patients. RESULTS: There were 7 female and 5 male patients. The mean age was 65.67 years (range 61-74 years). The median time interval between the onset of symptom and MRI scan was 47.5 hours, range 25-114 hours. 11 of the 12 patients showed punctate foci of restricted diffusion in hippocampus (mean size 3.7 mm (range 2-6.5 mm). 10 patients showed foci in left hippocampus. Nine patients showed a single focus, 1 patient showed three foci and 1 patient showed four foci. In 6 patients who had DWI MRI at both B values, scans at B value of 1000 s/mm2 revealed abnormality in 4 patients, while higher B value imaging improved sensitivity in one patient and one patient had a negative scan at both B values. CONCLUSION: We have highlighted the MRI finding of typical punctate foci of bright signal in hippocampus seen on DWI in patients diagnosed with TGA. Detection on a routine stroke MRI protocol can avoid need for dedicated TGA protocols or repeat scan, improving the workflow.

The Cost-Effectiveness of a Stroke Unit in Providing Enhanced Patient Outcomes in an Australian Teaching Hospital.

BACKGROUND: Stroke is one of the leading causes of disability and mortality. Patients who receive organized inpatient care in a stroke unit (SU) have better clinical outcomes. However, evidence on the cost analysis of an SU is lacking. The objective of this study was to assess the performance and analyze the cost-effectiveness of an SU. METHODS: A retrospective observational study was conducted comparing the acute stroke patient care in a 6-month period before and after the establishment of an acute SU at Calvary Hospital in 2013-2014. RESULTS: There were 103 patients included in the pre-SU period, as compared to 186 patients in the post-SU period. In the pre- and post-SU groups, 54 and 87 patients, respectively, had ischemic stroke, with significant trends in improved morbidity and mortality in the post-SU group (P = .01). The average length of stay (LOS) for patients was reduced from 9.7 days to 4.6 days in the post-SU group (P = .001). There was a reduction of cost per admission from $6382 Australian dollars (AUD) with conventional ward care as compared to $6061 (AUD) with SU care. CONCLUSION: This study confirmed that the establishment of an SU not only improves treatment outcomes but also shortens LOS, thereby achieving cost-effectiveness.

Should there be a standardised approach to the diagnostic workup of suspected adult encephalitis? A case series from Australia.

BACKGROUND: The clinical diagnosis of encephalitis is often difficult and identification of a causative organism is infrequent. The encephalitis syndrome may herald the emergence of novel pathogens with outbreak potential. Individual treatment and an effective public health response rely on identifying a specific pathogen. In Australia there have been no studies to try to improve the identification rate of encephalitis pathogens. This study aims to review the diagnostic assessment of adult suspected encephalitis cases. METHODS: A retrospective clinical audit was performed, of all adult encephalitis presentations between July 1998 and December 2007 to the three hospitals with adult neurological services in the Hunter New England area, northern New South Wales, Australia. Case notes were examined for evidence of relevant history taking, clinical features, physical examination, laboratory and neuroradiology investigations, and outcomes. RESULTS: A total of 74 cases were included in the case series. Amongst suspected encephalitis cases, presenting symptoms and signs included fever (77.0%), headache (62.1%), altered consciousness (63.5%), lethargy (32.4%), seizures (25.7%), focal neurological deficits (31.1%) and photophobia (17.6%). The most common diagnostic laboratory test performed was cerebrospinal fluid (CSF) analysis (n = 67, 91%). Herpes virus polymerase chain reaction (n = 53, 71.6%) and cryptococcal antigen (n = 46, 62.2%) were the antigenic tests most regularly performed on CSF. Neuroradiological procedures employed were computerized tomographic brain scanning (n = 68, 91.9%) and magnetic resonance imaging of the brain (n = 35, 47.3%). Thirty-five patients (47.3%) had electroencephalograms. The treating clinicians suspected a specific causative organism in 14/74 cases (18.9%), of which nine (12.1%) were confirmed by laboratory testing. CONCLUSIONS: The diagnostic assessment of patients with suspected encephalitis was not standardised. Appropriate assessment is necessary to exclude treatable agents and identify pathogens warranting public health interventions, such as those transmitted by mosquitoes and those that are vaccine preventable. An algorithm and guidelines for the diagnostic workup of encephalitis cases would assist in optimising laboratory testing so that clinical management can be best tailored to the pathogen, and appropriate public health measures implemented.