Asymptomatic spinal lesions in patients with AQP4-IgG-positive NMOSD: A real-world cohort study.

OBJECTIVE: This study aims to explore the frequency and influencing factors of asymptomatic spinal lesions (ASLs) and their impact on subsequent relapses in patients with AQP4-IgG-positive NMOSD (AQP4-NMOSD) in a real-world setting. METHODS: We retrospectively reviewed clinical information and spinal MRI data from AQP4-NMOSD patients who had at least one spinal cord MRI during their follow-ups. Kaplan-Meier curves and Cox proportional hazards models were employed to ascertain potential predictors of remission ASLs and to investigate factors associated with subsequent relapses. RESULTS: In this study, we included 129 patients with AQP4-NMOSD and reviewed 173 spinal MRIs during attacks and 89 spinal MRIs during remission. Among these, 6 ASLs (3.5%) were identified during acute attacks, while 8 ASLs (9%) were found during remission. Remission ASLs were linked to the use of immunosuppressive agents, particularly conventional ones, whereas no patients using rituximab developed ASLs (p = 0.005). Kaplan-Meier curve analysis indicated that patients with ASLs had a significantly higher relapse risk (HR = 4.658, 95% CI: 1.519-14.285, p = 0.007) compared to those without. Additionally, the use of mycophenolate mofetil (HR = 0.027, 95% CI: 0.003-0.260, p = 0.002) and rituximab (HR = 0.035, 95% CI: 0.006-0.203, p < 0.001) significantly reduced the relapse risk. However, after accounting for other factors, the presence of ASLs did not exhibit a significant impact on subsequent relapses (HR = 2.297, 95% CI: 0.652-8.085, p = 0.195). INTERPRETATION: ASLs may be observed in patients with AQP4-NMOSD. The presence of ASLs may signify an underlying inflammatory activity due to insufficient immunotherapy. The administration of immunosuppressive agents plays a key role in the presence of remission ASLs and the likelihood of subsequent relapses.

Prevalence and associated factors of basilar artery dolichosis in patients with acute cerebral infarction.

Introduction: Little attention has been given to the factors associated with basilar artery (BA) dolichosis. This study aims to elucidate the prevalence and associated factors of BA dolichosis in patients with acute cerebral infarction (ACI). Methods: We collected the clinical and laboratory data of 719 patients with ACI admitted to our department. Magnetic resonance angiography was used to evaluate the geometric parameters of the BA and intracranial vertebral arteries (VAs). A BA curve length > 29.5 mm or bending length (BL) > 10 mm was identified as BA dolichosis. Univariate and multivariate logistic regression were performed to determine the factors associated with BA dolichosis. Results: Among 719 patients with ACI, 238 (33.1%) demonstrated BA dolichosis, including 226 (31.4%) with simple BA dolichosis and 12 (1.7%) with basilar artery dolichoectasia (BADE). Pearson correlation analyses showed that BA curve length was positively correlated with BL (r = 0.605). Multivariate logistic regression analysis demonstrated that current smoking (OR = 1.50, 95% CI: 1.02-2.21, p = 0.039), diabetes mellitus (OR = 1.66, 95% CI: 1.14-2.41, p = 0.008), BA diameter (OR = 3.04, 95% CI: 2.23-4.13, p < 0.001), BA bending (OR = 4.24, 95% CI: 2.91-6.17, p < 0.001) and BL (OR = 1.45, 95% CI: 1.36-1.55, p < 0.001) were significantly associated with BA dolichosis. Conclusion: This study suggests that BA dolichosis was common in patients with ACI, and the morphological parameters of the vertebrobasilar artery and acquired risk factors (including smoking and diabetes) were risk factors for BA dolichosis.

Basilar artery curvature increases the risk of posterior circulation infarction occurrence in patients without vertebrobasilar stenosis.

INTRODUCTION: Limited cross-sectional or case-control studies have identified the relationship between basilar artery (BA) curvature and posterior circulation infarction (PCI). This study aimed to identify the influence of BA curvature severity on the risk of PCI occurrence in patients without vertebrobasilar stenosis through a prospective cohort study. METHODS: In this study, we enrolled 171 patients with BA dolichosis but without vertebrobasilar stenosis. The BA geometric parameters were evaluated on MRA. The primary outcome was the occurrence of PCI, mainly referring to cerebellar and/or brainstem infarction. Cox proportional hazard models were used to detect possible predictors of PCI. RESULTS: Among them, 134 (78.4%) patients were diagnosed with BA curvature, including 124 with moderate curvature and 10 with prominent curvature. The defined PCI occurrence was observed in 32 (18.7%) patients with a median follow-up time of 45.6 months. Cox proportional hazard analysis showed that BA prominent curvature (HR = 6.09; 95% CI: 1.36-27.28; P = 0.018) significantly increased the risk of PCI occurrence, and bending length (BL) was also significantly associated with PCI occurrence, with the adjusted HR per 1-mm increase of BL of 1.09 (95% CI: 1.01-1.18; P = 0.040). In the subgroup analysis stratified by age, BA prominent curvature was highly associated with PCI occurrence in patients aged > 61 years (HR = 11.76; 95% CI: 1.21-113.90; P = 0.033). Additionally, good antiplatelet therapy adherence could significantly reduce the risk of PCI occurrence. CONCLUSION: BA curvature may increase the risk of PCI occurrence, especially in elderly patients with prominent curvature. Improving adherence to antiplatelet therapy can help reduce the risk of PCI occurrence.

Increased neutrophil-to-lymphocyte ratio is associated with unfavorable functional outcomes in acute pontine infarction.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) is positively associated with unfavorable outcomes in patients with cerebral infarction. This study aimed to investigate the relationship between the NLR and the short-term clinical outcome of acute pontine infarction. METHODS: Patients with acute pontine infarction were consecutively included. Clinical and laboratory data were collected. All patients were followed up at 3 months using modified Rankin Scale (mRS) scores. An unfavorable outcome was defined as an mRS score ≥ 3. Receiver operating characteristic (ROC) curve analysis was used to calculate the optimal cutoff values for patients with acute pontine infarction. risk factors can be predictive factors for an unfavorable outcome after acute pontine infarction. RESULTS: Two hundred fifty-six patients with acute pontine infarction were included in this study. The NLR was significantly higher in the unfavorable outcome group than in the favorable outcome group (P < 0.05). Additionally, the infarct size was significantly higher in the high NLR tertile group than in the low NLR tertile group (P < 0.05). Multivariate logistic regression analysis revealed that the baseline National Institutes of Health Stroke Scale (NIHSS) score, NLR, platelet count, and fasting blood glucose (FBG) level were significantly associated with unfavorable outcomes 3 months after acute pontine infarction. The optimal cutoff value of the NLR for predicting the 3-month outcome of acute pontine infarction was 3.055. The negative and positive predictive values of NLR were 85.7% and 61.3%, respectively, and the sensitivity and specificity of NLR were 69.2% and 80.9%. CONCLUSIONS: We found that the NLR may be an independent predictive factor for the outcome of acute pontine infarction.

The Relationship Between the Fibrinogen to Albumin Ratio and Early Outcomes in Patients with Acute Pontine Infarction.

BACKGROUND AND PURPOSE: Previous studies have indicated that fibrinogen and low serum albumin levels are associated with poor outcomes of acute ischemic stroke. The role of the fibrinogen-to-albumin ratio (FAR) as a novel inflammatory and thrombotic biomarker in acute ischemic stroke is unclear. This study aims to investigate the relationship between the FAR and 3-month outcomes of acute pontine infarction. Methods: Patients with acute pontine infarction were consecutively included. All patients were followed up at 3 months after onset, and the 3-month outcome was evaluated using modified Rankin Scale (mRS) scores. A score of 0 to 2 was defined as a good outcome, and a score ≥ 3 was defined as a poor outcome. Receiver operating curve (ROC) analysis was used to calculate the optimal cutoff values for patients with acute pontine infarction. Then, a binary logistic regression model was used to evaluate the risk factors for a poor outcome after acute pontine infarction. Results: A total of 264 patients with acute pontine infarction were included. Eighty (30.3%) patients were included in the poor outcome group. The optimal cutoff value of the FAR for predicting the 3-month outcome of acute pontine infarction was 8.199. The FAR was independently associated with a poor outcome at 3 months in patients with acute pontine infarction (odds ratio [OR] = 1.293, 95% confidence interval [CI]: 1.150-1.453). Conclusions: We found that a high FAR predicted poor 3-month outcomes in patients with acute pontine infarction.

Moving silicone oil particles in the ventricle: a case report and updated review.

BACKGROUND: The movement of intraventricular silicone oil observed in the supine position is extremely rare. Herein, we describe a patient who presented with dynamically moving silicone oil particles in the ventricle when changing position and provide an updated review of this phenomenon. CASE PRESENTATION: We report a case of a 70-year-old woman who presented with intraventricular hyperdensities that were occasionally found on brain computed tomography (CT). Initial nonenhanced brain CT demonstrated nondependent hyperdensities in the bilateral anterior horns of the lateral ventricles, the third ventricle, and the right suprasellar cistern, mimicking an intraventricular hemorrhage. Further brain magnetic resonance imaging (MRI) in the supine position revealed abnormal signals in the bilateral anterior horns of the lateral ventricles, the posterior horn of the right lateral ventricle, the third ventricle, the right suprasellar cistern, and the bilateral eyeballs, with isosignal intensities surrounded by low-signal chemical shift artifacts on T1-weighted imaging and variable signals (hypo- or hyperintensity) on T2-weighted imaging. The lesion in the anterior horn of the right ventricle largely moved to the posterior horn of the ipsilateral ventricle. The final craniocervical CT angiography showed that the lesion in the posterior horn had moved back to the anterior horn of the right lateral ventricle. These features were consistent with intraventricular silicone oil migration. The final spinal MRI did not demonstrate a migration of silicone oil into the spinal subarachnoid space. DISCUSSION AND CONCLUSIONS: This case report describes a dynamic process of silicone oil displacement in the supine position and provides a comprehensive imaging presentation. The moving pattern and a characteristic chemical shift artifact on MRI are key to the diagnosis and may help prevent unnecessary examinations or intervention.

Basilar Artery Dolichosis Increases the Risk of Long-Term Recurrence in Patients With Pontine Infarction: A Prospective Cohort Study.

Background and Purpose: Patients with basilar artery (BA) dolichosis are at high risk of acute pontine infarction (API), but the association between BA dolichosis and long-term stroke recurrence has received little attention. We aimed to identify the effect of BA dolichosis on the risk of long-term brainstem infarction recurrence in patients with API. Methods: In this prospective cohort study, we enrolled 113 patients with API admitted to our department. BA dolichosis was diagnosed by a BA curve length >29.5 mm or bending length (BL) >10 mm on magnetic resonance angiography. The primary outcome was the occurrence of diffusion-weighted imaging (DWI)-confirmed brainstem infarction. The Cox proportional hazard model was used to detect possible predictors of brainstem infarction recurrence. Results: Among 113 patients with API, 39 (34.5%) patients had BA dolichosis, and DWI-confirmed brainstem infarction recurred in 15 (13.3%) patients with a mean follow-up time of 31.2 months; the estimated 5-year incidence of brainstem infarction recurrence was 23.1% in patients with BA dolichosis, which was significantly higher than the incidence of 8.1% in patients without BA dolichosis. Cox proportional hazard analysis showed that age ≥65 years (hazard ratio (HR) = 3.341, 95% confidence interval (CI): 1.079-10.348, P = 0.036) and BA dolichosis (HR = 3.048, 95% CI: 1.069-8.693, P = 0.037) were significantly associated with a higher risk of brainstem infarction recurrence. In a subgroup analysis stratified by age, the patients aged ≥65 years with BA dolichosis had a higher risk of brainstem infarction recurrence (HR = 7.319, 95% CI: 1.525-35.123, P = 0.013). Conclusions: This study indicates that BA dolichosis may increase the risk of long-term brainstem infarction recurrence in patients with API, especially in elderly patients, and therefore warrants more attention in clinical practice.

Laboratory Predictors of COVID-19 Pneumonia in Patients with Mild to Moderate Symptoms.

OBJECTIVE: This research aims to develop a laboratory model that can accurately distinguish pneumonia from nonpneumonia in patients with COVID-19 and to identify potential protective factors against lung infection. METHODS: We recruited 50 patients diagnosed with COVID-19 infection with or without pneumonia. We selected candidate predictors through group comparison and punitive least absolute shrinkage and selection operator (LASSO) analysis. A stepwise logistic regression model was used to distinguish patients with and without pneumonia. Finally, we used a decision-tree method and randomly selected 50% of the patients 1000 times from the same specimen to verify the effectiveness of the model. RESULTS: We found that the percentage of eosinophils, a high-fluorescence-reticulocyte ratio, and creatinine had better discriminatory power than other factors. Age and underlying diseases were not significant for discrimination. The model correctly discriminated 77.1% of patients. In the final validation step, we observed that the model had an overall predictive rate of 81.3%. CONCLUSION: We developed a laboratory model for COVID-19 pneumonia in patients with mild to moderate symptoms. In the clinical setting, the model will be able to predict and differentiate pneumonia vs nonpneumonia before any lung computed tomography findings. In addition, the percentage of eosinophils, a high-fluorescence-reticulocyte ratio, and creatinine were considered protective factors against lung infection in patients without pneumonia.

Anton's syndrome as a presentation of Trousseau syndrome involving the bilateral optic radiation.

Anton's syndrome is a rare neuropsychiatric syndrome that is characterized by cortical blindness and anosognosia with visual confabulation, but without global cognitive impairment. We herein report a rare case of Anton's syndrome as a presentation of Trousseau syndrome involving the bilateral optic radiation. The patient had been diagnosed with gallbladder cancer 2 months previously, and he was admitted to the hospital with confusion and quadriplegia. He was found to be blind, but denied any visual impairment and demonstrated visual confabulation despite evidence of his blindness. These signs were consistent with a diagnosis of Anton's syndrome. Brain computed tomography (CT) and magnetic resonance imaging revealed infarcts in the bilateral temporo-parieto-occipital junction with hemorrhagic transformation, mainly involving the bilateral optic radiation. The presence of gallbladder cancer with peripheral metastasis on abdominal CT, as well as markedly increased tumor markers and D-dimer levels, supported the presence of cancer-related hypercoagulability and the diagnosis of Trousseau syndrome.

Fungal endocarditis with heart valve replacement and atrial fibrillation posing a treatment challenge: A case report.

RATIONALE: Fungal endocarditis (FE) is a rare disease, in which antifungal treatment is necessary. When FE is complicated with prosthetic heart valve and/or atrial fibrillation, the coadministration of antifungal agents and warfarin is inevitable. We report a case of rheumatic heart disease with atrial fibrillation who developed FE following prosthetic heart valve replacement. The international normalized ratio (INR) increased significantly during the antifungal treatment with fluconazole. A discussion of the antifungal strategy in FE patients with prosthetic heart valves and/or atrial fibrillation and the interaction between antifungal agents and warfarin was performed. PATIENT CONCERNS: A 54-year-old Chinese woman experienced intermittent fevers, aphemia, and weakness in her right extremities. Her temperature was 38.7°C, and there was atrial fibrillation with heart rate 110 times/min. Neurological examination revealed that she had drowsiness, Broca aphasia, right central facial paralysis, and hemiplegia (Medical Research Council scale, upper limb grade 0, lower limb grade II). DIAGNOSES: Multiple infarction on magnetic resonance imaging and the occlusion of left middle cerebral artery suggested the occurrence of cerebral embolism. The presence of Candida parapsilosis in the results of 4 blood cultures and the existence of valve vegetation in the reexamination of echocardiogram supported the diagnosis of FE. INTERVENTIONS: The patient was given antifungal therapy with fluconazol. The INR increased dramatically on the 9th day of antifungal treatment, and subcutaneous bruising occurred at the intravenous infusion site. The antagonist of vitamin K1 was used and warfarin was reduced to a smaller dosage. The antifungal agent was replaced with caspofungin. OUTCOMES: Her speech improved significantly, and the muscle strength of her paralyzed side reached the Medical Research Council scale of grade IV. She continued to receive caspofungin for antifungal treatment with relatively stable INR and waited for heart valve surgery. LESSONS: The choice of antifungal agents is often a big challenge for FE patients, especially when they need warfarin for anticoagulation. It is better to administer a low dose of warfarin while carefully monitoring the INR or choose the antifungal drugs with little or no effect on warfarin.

Genetically Confirmed CARASIL: Case Report with Novel HTRA1 Mutation and Literature Review.

BACKGROUND: Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL) is an extremely rare monogenic autosomal disease associated with the HtrA serine protease 1 (HTRA 1) gene mutation. Recently, a few genetically confirmed CARASIL cases with novel HTRA1 mutations have been reported in countries other than Japan. CASE DESCRIPTION: Here, we report a case of a patient presenting with worsening right hemiplegia and hemiparesthesia. Physical examination revealed that the patient had typical clinical features of CARASIL including thinning hair, cognitive impairment, emotional changes, lumbago, and gait disorder. Brain magnetic resonance imaging showed abnormal diffuse symmetric changes in white matter and hypertensive diffusion-weighted imaging signals in the left centrum ovale and right splenium of the corpus callosum, and susceptibility-weighted imaging showed multiple cerebral microbleeds. Lumbar magnetic resonance imaging showed herniated disks with degenerative changes. A genetic test showed a novel homozygous nucleotide variation of c.847G>T in the HTRA1 gene, thereby resulting in p.Gly283Ter. Thus the patient met the diagnostic criteria for CARASIL. We provide a literature review of genetically confirmed CARASIL cases reported to date. CONCLUSIONS: CARASIL is a rare autosomal recessive disease with an HTRA1 mutation. Familiarity with the early clinical and imaging features of CARASIL combined with a genetic test is key for its early diagnosis.