Brucellosis is a multisystem zoonotic disease. We report an unusual case of neurobrucellosis with seizures in an immunocompromised patient in Saudi Arabia who underwent renal transplantation. ...Magnetic resonance imaging of the brain showed diffuse white matter lesions. Serum and cerebrospinal fluid were positive for Brucella sp. Granuloma was detected in a brain biopsy specimen.
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DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IMPORTANCE: Recanalization of intracranial thrombus is associated with improved clinical outcome in patients with acute ischemic stroke. The association of intravenous alteplase treatment and ...thrombus characteristics with recanalization over time is important for stroke triage and future trial design. OBJECTIVE: To examine recanalization over time across a range of intracranial thrombus occlusion sites and clinical and imaging characteristics in patients with ischemic stroke treated with intravenous alteplase or not treated with alteplase. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective cohort study of 575 patients from 12 centers (in Canada, Spain, South Korea, the Czech Republic, and Turkey) with acute ischemic stroke and intracranial arterial occlusion demonstrated on computed tomographic angiography (CTA). EXPOSURES: Demographics, clinical characteristics, time from alteplase to recanalization, and intracranial thrombus characteristics (location and permeability) defined on CTA. MAIN OUTCOMES AND MEASURES: Recanalization on repeat CTA or on first angiographic acquisition of affected intracranial circulation obtained within 6 hours of baseline CTA, defined using the revised arterial occlusion scale (rAOL) (scores from 0 primary occlusive lesion remains the same to 3 complete revascularization of primary occlusion). RESULTS: Among 575 patients (median age, 72 years IQR, 63-80; 51.5% men; median time from patient last known well to baseline CTA of 114 minutes IQR, 74-180), 275 patients (47.8%) received intravenous alteplase only, 195 (33.9%) received intravenous alteplase plus endovascular thrombectomy, 48 (8.3%) received endovascular thrombectomy alone, and 57 (9.9%) received conservative treatment. Median time from baseline CTA to recanalization assessment was 158 minutes (IQR, 79-268); median time from intravenous alteplase start to recanalization assessment was 132.5 minutes (IQR, 62-238). Successful recanalization occurred at an unadjusted rate of 27.3% (157/575) overall, including in 30.4% (143/470) of patients who received intravenous alteplase and 13.3% (14/105) who did not (difference, 17.1% 95% CI, 10.2%-25.8%). Among patients receiving alteplase, the following factors were associated with recanalization: time from treatment start to recanalization assessment (OR, 1.28 for every 30-minute increase in time 95% CI, 1.18-1.38), more distal thrombus location, eg, distal M1 middle cerebral artery (39/84 46.4%) vs internal carotid artery (10/92 10.9%) (OR, 5.61 95% CI, 2.38-13.26), and higher residual flow (thrombus permeability) grade, eg, hairline streak (30/45 66.7%) vs none (91/377 24.1%) (OR, 7.03 95% CI, 3.32-14.87). CONCLUSIONS AND RELEVANCE: In patients with acute ischemic stroke, more distal thrombus location, greater thrombus permeability, and longer time to recanalization assessment were associated with recanalization of arterial occlusion after administration of intravenous alteplase; among patients who did not receive alteplase, rates of arterial recanalization were low. These findings may help inform treatment and triage decisions in patients with acute ischemic stroke.
Objectives The benefits of intravenous thrombolysis are time‐dependent, with maximum efficacy when administered within the first “golden” hour after onset. Nevertheless, the impact of golden hour ...thrombolysis has not been well quantified. Methods Medline, Embase, and Web of Science databases were systematically searched from inception to August 27, 2023. We included studies that reported safety and efficacy outcomes of ischemic stroke patients treated with intravenous thrombolysis in the golden hour versus later treatment window. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale score of 0–1 at 90 days. The secondary efficacy outcome was a good functional outcome (defined as modified Rankin Scale score of 0–2). The main safety outcome was symptomatic intracerebral hemorrhage. Results Seven studies involving 78,826 patients met the selection criteria. Golden hour thrombolysis was associated with higher odds of 90‐day excellent functional outcomes (OR 1.40, 95% CI 1.16–1.67) and 90‐day good functional outcomes (OR 1.38, 95% CI 1.13–1.69) compared with thrombolysis outside the golden hour. The number needed to treat to benefit for golden hour thrombolysis to reduce disability by at least 1 level on the modified Rankin Scale per patient was 2.6. Rates of symptomatic intracerebral hemorrhage and mortality were similar between groups. Interpretation Golden hour thrombolysis significantly improved acute ischemic stroke outcomes. The findings provide rationale for intensive efforts aimed at expediting thrombolytic therapy within the golden hour window following the onset of acute ischemic stroke. ANN NEUROL 2024
BACKGROUND AND PURPOSE—Early hematoma expansion after intracerebral hemorrhage is a potentially modifiable predictor of outcome and a promising therapeutic target. Radiological markers seen on ...noncontrast computed tomography can help predict hematoma expansion and risk stratify patients presenting with intracerebral hemorrhage. Our objective was to assess the interrater and intrarater reliability of 5 commonly reported noncontrast computed tomographic markers of hematoma expansion.
METHODS—Four readers independently reviewed images from 40 patients from 2 intracerebral hemorrhage imaging databases (PREDICT Collaboration Predicting Haematoma Growth and Outcome in Intracerebral Haemorrhage Using Contrast Bolus CT and Massachusetts General Hospital). Readers were blind to all demographic and outcome data and used accepted definitions to establish the presence or absence of intrahematoma hypodensities, blend sign, fluid level, irregular hematoma morphology, and heterogeneous hematoma density. We calculated interrater and intrarater agreement and stratified kappas for the 5 imaging markers.
RESULTS—Interrater agreement was excellent for all 5 markers, ranging from 94% to 98%. Interrater kappas ranged from 0.67 to 0.91 (the lowest for fluid level). Interrater agreement had a similar pattern, ranging from 89% to 93%, with Kappas ranging from 0.60 to 0.89.
CONCLUSIONS—We show that 5 commonly used noncontrast computed tomographic imaging findings all have good-to-excellent interrater and intrarater reliabilities, with the best kappa for blend sign, hypodensities, and heterogeneity.
Background In acute ischemic stroke caused by large‐vessel occlusion, tissue viability is dependent on the blood supply from leptomeningeal collaterals until reperfusion is achieved. Rapid and ...accurate evaluation of baseline collateral status is a key marker of eligibility for endovascular therapy but can be challenging to interpret using source images of the computed tomography angiography (SI‐CTA). Our objective was to assess whether the use of thick maximum‐intensity projection computed tomography angiography (MIP‐CTA) improves interrater agreement for evaluation of baseline collaterals status between stroke trainees and an expert stroke neurologist. Methods An expert stroke neurologist and 2 stroke trainees independently reviewed images from 40 brain CTA scans with anterior circulation large‐vessel occlusion and assessed collateral status using the Tan collateral scoring system using SI‐CTA in the first reading and then using MIP‐CTA in the second reading. We calculated interrater agreement and recorded the total time needed in each reading. Results Interrater agreement was fair between the 2 stroke fellows and stroke expert when using SI‐CTA (κ=0.45 with 52.5% agreement). After using MIP‐CTA, interrater agreement improved to moderate (κ=0.69 with 70% agreement). The median reading time was 1.89 minutes per scan using SI‐CTA and 1.00 minute per scan using MIP‐CTA ( P <0.0001). Conclusions We show that using MIP‐CTA, when compared with SI‐CTA, shortens interpretation time and improves interrater agreement between stroke trainees and a stroke imaging expert for the evaluation of baseline collaterals in patients presenting with anterior circulation large‐vessel occlusion.
Woodhouse–Sakati syndrome (WSS) is a rare autosomal recessive disease with characteristic neuro-endocrine manifestations. WSS encompasses heterogeneous phenotypes and disease course.
We aimed to ...characterize neurological involvement of the disease through subgrouping of core neurological manifestations.
A single-institution retrospective analysis of patients with clinically and genetically confirmed diagnosis of WSS.
A total of 38 individuals belonging to 17 families were identified to have WSS. The mean age at enrollment was 30.1 years (range 16–53 years). Neurological involvement was noted in 31 patients (81.5%). Dystonia was the most common neurological manifestation (67%), followed by intellectual disability (45%) and sensorineural hearing loss (30%). Based on the Neurological Impairment Scale (NIS), the disease was recognized to have two distinct patterns. A disabling, rapidly progressive pattern (NIS of 3–4; Type 1) was noted in eighteen patients (12 males, 6 females; 47.4%) with severe disability that occurs within a mean duration of 7.4 ± 3.6 years. Type 2 WSS was identified in twenty patients (8 males, 12 females; 52.6%), and showed either absent or mild neurological involvement with preserved activities of daily living (NIS of 0–1). The mean age of onset for neurological manifestations was earlier in type 1 (12.6 ± 4.5 years) compared to type 2 (18.1 ± 4.3 years). Type 1 WSS has a significantly higher rate of intellectual disability (p= <0.001).
In this pleiotropic syndrome, we identified two distinct phenotypes with variable prognosis. A high Interfamilial and intrafamilial phenotypic variability despite having a similar gene mutation suggests a possible role of genetic or environmental modifying factor.
•Woodhouse-Sakati syndrome (WSS) is a pleiotropic syndrome with variable neurological manifestations.•Two distinct phenotypes were recognized in our study.•Gene modifier factor has potential role to cause interfamilial and intrafamilial phenotypic variability.
There is interest in what happens over time to the thrombus after intravenous alteplase. We study the effect of alteplase on thrombus structure and its impact on clinical outcome in patients with ...acute stroke.
Intravenous alteplase treated stroke patients with intracranial internal carotid artery or middle cerebral artery occlusion identified on baseline computed tomography angiography and with follow-up vascular imaging (computed tomography angiography or first run of angiography before endovascular therapy) were enrolled from INTERRSeCT study (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography). Thrombus movement after intravenous alteplase was classified into complete recanalization, thrombus migration, thrombus fragmentation, and no change. Thrombus migration was diagnosed when occlusion site moved distally and graded according to degrees of thrombus movement (grade 0-3). Thrombus fragmentation was diagnosed when a new distal occlusion in addition to the primary occlusion was identified on follow-up imaging. The association between thrombus movement and clinical outcome was also evaluated.
Among 427 patients in this study, thrombus movement was seen in 54% with a median time of 123 minutes from alteplase administration to follow-up imaging, and sub-classified as marked (thrombus migration grade 2-3 + complete recanalization; 27%) and mild to moderate thrombus movement (thrombus fragmentation + thrombus migration grade 0-1; 27%). In patients with proximal M1/internal carotid artery occlusion, marked thrombus movement was associated with a higher rate of good outcome (90-day modified Rankin Scale, 0-2) compared with mild to moderate movement (52% versus 27%; adjusted odds ratio, 5.64 95% CI, 1.72-20.10). No difference was seen in outcomes between mild to moderate thrombus movement and no change. In M1 distal/M2 occlusion, marked thrombus movement was associated with improved 90-day good outcome compared with no change (70% versus 56%; adjusted odds ratio, 2.54 95% CI, 1.21-5.51).
Early thrombus movement is common after intravenous alteplase. Marked thrombus migration leads to good clinical outcomes. Thrombus dynamics over time should be further evaluated in clinical trials of acute reperfusion therapy.
Background
Some patients with ischemic stroke have poor outcomes despite small infarcts after endovascular thrombectomy, while others with large infarcts sometimes fare better.
Aims
We explored ...factors associated with such discrepancies between post-treatment infarct volume (PIV) and functional outcome.
Methods
We identified patients with small PIV (volume ≤ 25th percentile) and large PIV (volume ≥ 75th percentile) on 24–48-h CT/MRI in the ESCAPE randomized-controlled trial. Demographics, comorbidities, baseline, and 24–48-h stroke severity (NIHSS), stroke location, treatment type, post-stroke complications, and other outcome scales like Barthel Index, and EQ-5D were compared between “discrepant cases” – those with 90-day modified Rankin Scale(mRS) ≤ 2 despite large PIV or mRS ≥ 3 despite small PIV – and “non-discrepant cases”. Multi-variable logistic regression was used to identify pre-treatment and post-treatment factors associated with small-PIV/mRS ≥ 3 and large-PIV/mRS ≤ 2. Sensitivity analyses used different definitions of small/large PIV and good/poor outcome.
Results
Among 315 patients, median PIV was 21 mL; 27/79 (34.2%) patients with PIV ≤ 7 mL (25th percentile) had mRS ≥ 3; 12/80 (15.0%) with PIV ≥ 72 mL (75th percentile) had mRS ≤ 2. Discrepant cases did not differ by CT versus MRI-based PIV ascertainment, or right versus left-hemisphere involvement (p = 0.39, p = 0.81, respectively, for PIV ≤ 7 mL/mRS ≥ 3). Pre-treatment factors independently associated with small-PIV/mRS ≥ 3 included older age (p = 0.010), cancer, and vascular risk-factors; post-treatment factors included 48-h NIHSS (p = 0.007) and post-stroke complications (p = 0.026). Absence of vascular risk-factors (p = 0.004), CT-based lentiform nucleus sparing (p = 0.002), lower 24-hour NIHSS (p = 0.001), and absence of complications (p = 0.013) were associated with large-PIV/mRS ≤ 2. Sensitivity analyses yielded similar results.
Conclusions
Discrepancies between functional ability and PIV are likely explained by differences in age, comorbidities, and post-stroke complications, emphasizing the need for high-quality post-thrombectomy stroke care.
Clinical trial registration
https://clinicaltrials.gov/ct2/show/NCT01778335.
BACKGROUND AND PURPOSE—Infarct in a new previously unaffected territory (INT) is a potential complication of endovascular treatment. We applied a recently proposed methodology to identify and ...classify INTs in the ESCAPE randomized controlled trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times).
METHODS—The core laboratory identified INTs on 24-hour follow-up imaging, blinded to treatment allocation, after assessing all baseline imaging. INTs were classified into 3 types (I–III) and 2 subtypes (A/B) based on size and if catheter manipulation was likely performed across the vessel territory ostium. Logistic regression was used to understand the effect of multiple a priori identified variables on INT occurrence. Ordinal logistic regression was used to analyze the effect of INTs on modified Rankin Scale shift at 90 days.
RESULTS—From 308 patients included, 14 INTs (4.5% overall; 2.8% on follow-up noncontrast computed tomography, 11.7% on follow-up magnetic resonance imaging) were identified (5.0% in endovascular treatment arm versus 4.0% in control arm P=0.7). The use of intravenous alteplase was associated with a 68% reduction in the odds of INT occurrence (3.0% with versus 9.1% without; odds ratio, 0.32; 95% confidence interval, 0.11–0.96; adjusted for age, sex, and treatment type). No other variables were associated with INTs. INT occurrence was associated with reduced probability of good clinical outcome (common odds ratio, 0.25; 95% confidence interval, 0.09–0.74; adjusted for age, type of treatment, and follow-up scan).
CONCLUSIONS—INTs are uncommon, detected more frequently on follow-up magnetic resonance imaging, and affect clinical outcome. In experienced centers, endovascular treatment is likely not causal, whereas intravenous alteplase may be therapeutic.
CLINICAL TRIAL REGISTRATION—URLhttp://www.clinicaltrials.gov. Unique identifierNCT01778335.
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