Warfarin versus aspirin for prevention of stroke in heart failure: a meta-analysis of randomized controlled clinical trials.

BACKGROUND: There is clinical equipoise between warfarin and aspirin for stroke prevention in patients with heart failure in sinus rhythm (SR). The objective of this meta-analysis was to pool risk estimates for stroke, mortality, and intracerebral hemorrhage (ICH) from published clinical randomized controlled trials (RCTs). METHODS: MEDLINE, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched for English-language RCTs comparing warfarin to aspirin in heart failure through May 2012. Pooled relative risk (RR) was calculated from a random-effects model. RESULTS: Four RCTs (n=3681) met the criteria for study inclusion. Warfarin was associated with a lower risk of stroke compared with aspirin (pooled RR, .59; 95% confidence interval [CI], .41-.85; P=.004). The number needed to treat (NNT) was 61. There was no difference between warfarin and aspirin in mortality (pooled RR, 1; 95% CI, .88-1.13), and ICH (pooled RR, 2.17; 95% CI, .76-6.24). Among secondary outcomes, warfarin was associated with almost twice the risk of major hemorrhage (pooled RR, 1.95; 95% CI, 1.37-2.76; P=.0001) compared with aspirin. The number needed to harm (NNH) was 34. There was no significant difference between warfarin and aspirin in risk of myocardial infarction (MI) (pooled RR, 1.02; 95% CI, .65-1.6], and heart failure exacerbation (HFE) (pooled RR, 1.11; 95% CI, .76-1.63). CONCLUSIONS: Compared with aspirin, warfarin reduced the risk of stroke while conferring an increased risk of major hemorrhage. Warfarin does not increase mortality or confer an increased risk of ICH compared with aspirin.

Isolated hypersomnia due to bilateral thalamic infarcts.

We describe a unique patient who developed hypersomnia as the sole presenting symptom of bilateral thalamic infarcts.

Electroencephalographic abnormalities in baclofen-induced encephalopathy.

We report a patient in whom the characteristic electroencephalographic features of baclofen intoxication are highlighted and emphasize the role of electrographic abnormalities in the diagnosis of this condition.

Lentiform Fork sign: a unique MRI picture. Is metabolic acidosis responsible?

BACKGROUND AND PURPOSE: Bilateral basal ganglia lesions are neither diagnostic nor pathognomonic of uremic encephalopathy (UE). Nonetheless, bilateral basal ganglia T2/FLAIR hyperintensities have been widely reported to be associated with UE. The aim of this study was to describe a unique neuroradiological sign seen on the MRI brain in UE, present a retrospective chart review of patients with UE over the past 10 years for evidence of similar MRI appearance, review literature for evidence of this sign, and generate a hypothesis to explain its pathophysiological basis. METHODS: We describe a previously unreported and unique MRI picture, the Lentiform Fork sign, in a patient with UE. We conducted a focused retrospective chart review of patients with UE over the past 10 years, for evidence of similar MRI changes. We review literature (through PUBMED, OVID, and CENTRAL) for evidence of this sign and propose a hypothesis to explain the basis of this MRI sign. RESULTS: We describe the Lentiform Fork sign in a patient with UE. Of our 21 retrospectively reviewed patients with UE who underwent MRI, only one had this sign. Literature review identified 22 patients with this sign who had various conditions, all associated with metabolic acidosis. Fourteen of these patients had documented evidence of severe metabolic acidosis. We propose the hypothesis that metabolic acidosis is the basis of this Lentiform Fork sign. CONCLUSION: Lentiform Fork sign is a unique, previously unreported MRI picture that is seen not only in patients with UE but also in other conditions that result in metabolic acidosis, helping discriminate a specific etiology from the myriad of conditions that are lumped under the rubric of "basal ganglia hyperintensity." We propose the hypothesis that metabolic acidosis may be the key factor in the pathogenesis of this sign.

Reversible sensorineural hearing loss with normal brainstem auditory evoked potentials in pontine hemorrhage due to capillary telangiectasia.

Capillary telangiectasias are vascular malformations most commonly found in the pons that are rarely associated with hemorrhage. We describe a unique case of pontine capillary telangiectasia causing central brainstem hemorrhage leading to reversible sensorineural deafness associated with a normal brainstem auditory evoked response.

Penumbra, the basis of neuroimaging in acute stroke treatment: current evidence.

In modern medicine brain imaging is an essential prerequisite not only to acute stroke triage but also to determining the specific therapy indicated. This article reviews the need for imaging the brain in acute stroke, penumbral pathophysiology, penumbral imaging techniques, as well as current status of various imaging modalities that are being employed to select patients for specific therapeutic approaches.

Necrobacillosis resulting in isolated carotid thrombosis and massive stroke: a unique Lemierre variant?

We describe a healthy, young adult male patient who developed isolated carotid artery thrombosis and occlusion following acute pharyngitis due to Fusobacterium necrophorum. We believe this is the first case of isolated occlusion of internal carotid artery (ICA) with F.necrophorum without associated internal jugular vein (IJV) thrombosis. Lemierre's syndrome (LS) is characterized by a history of recent oropharyngeal infection in previously healthy individuals, clinical or radiological evidence of internal jugular vein thrombosis, and isolation of anaerobic pathogens, mainly F.necrophorum. We discuss literature on this rare, previously unreported, variant of LS.