Emergent use of ticagrelor during endovascular reperfusion in large arterial occlusions

OBJECTIVE

Given many emerging indications for endovascular interventions in ischemic strokes, a safe and effective adjuvant antiplatelet regimen for acute revascularization has become a subject of interest. Ticagrelor is a direct oral P2Y12 inhibitor that may achieve rapid platelet suppression than standard oral therapies. We report our experience of Ticagrelor use in revascularization of acute large arterial steno-occlusive disease, describing procedural post-procedure thrombotic events, major hemorrhages, and other clinical outcomes.

METHODS

This was a single-center retrospective case series of large steno-occlusive disease requiring endovascular reperfusion with emergent adjuvant Ticagrelor, defined as 30 min of the procedure from skin puncture to closure of the arteriotomy. Major outcomes investigated were thromboembolism in the target artery, and symptomatic intracranial or extracranial major hemorrhages. Additional analyses were performed with respect to timing of the administration and use of rescue GPIIb/IIIa inhibitors if any.

RESULTS

73 consecutive patients were identified, presenting with severe ischemic stroke (median NIHSS 16) of large artery origin. 67% required stent placement (45% cervical carotid, 22% intracranial artery), 9.5% angioplasty and 23% mechanical thrombectomy only. Two experienced symptomatic in-stent occlusion, and 7 experienced major hemorrhages (9.5%) including 3 fatal symptomatic intracranial hemorrhages (4.1%). Among 19 subjects (26%) who received pretreatment with Ticagrelor, there were fewer GPIIb/IIIa administration, angioplasty and stenting, without yielding benefit in functional outcome or mortality. GPIIb/IIIa was administered as rescue therapy in 45 subjects (62%), which was found associated with increased bleeding compared to patients receiving Ticagrelor only, in whom no bleeding complications were recorded (16% vs. 0%; p = 0.03).

CONCLUSION

We report our findings on Ticagrelor as an adjuvant antiplatelet therapy in ischemic stroke of large arterial origin requiring emergent revascularization. Effectiveness, safety, need for additional rescue treatment, and comparison to other commonly used oral antiplatelets should be investigated in future prospective studies.

Prehospital stroke scales outperform National Institutes of Health Stroke Scale in predicting large vessel occlusion in a large academic telestroke network

INTRODUCTION

Prehospital telestroke evaluations may improve stroke triage compared to paramedic-applied large vessel occlusion scales, but ambulance-based video National Institutes of Health Stroke Scale assessments are challenging. The accuracy of telestroke-administered large vessel occlusion scales has not been investigated, so we sought to evaluate this further.

METHODS

This retrospective study included all in-hospital telestroke encounters in a large academic telestroke network from 2019 to 2020. We retrospectively calculated seven large vessel occlusion scales using the in-hospital telestroke National Institutes of Health Stroke Scale (Rapid Arterial oCclusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Prehospital Acute Stroke Severity, Vision-Aphasia-Neglect, and Gaze-Face-Arm-Speech-Time). Diagnostic performance was assessed via sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, negative likelihood ratio, and accuracy using established scale thresholds. These results were compared to the National Institutes of Health Stroke Scale at thresholds of 6, 8, and 10. The area under curve was calculated using c-statistics by treating scales as continuous variables.

RESULTS

A total of 625 patients were included; 111 (17.8%) patients had an anterior large vessel occlusion, 118 (18.9%) patients had any large vessel occlusion, and 182 (29.1%) patients had stroke mimic diagnosis. The mean age (SD) was 67.9 (15.9), 48.3% were female, and 93.4% were white. The Mean National Institutes of Health Stroke Scale (SD) was 14.9 (8.4) for patients with anterior large vessel occlusion, 4.7 (5.0) for patients with non-large vessel occlusion ischemic stroke, and 4.4 (5.8) for stroke mimic (p < 0.001). Compared to the National Institutes of Health Stroke Scale, Field Assessment Stroke Triage for Emergency Destination, and Rapid Arterial oCclusion Evaluation scales demonstrated higher accuracy and area under curve for large vessel occlusion detection.

DISCUSSION

Both the Field Assessment Stroke Triage for Emergency Destination and Rapid Arterial oCclusion Evaluation scales outperformed the National Institutes of Health Stroke Scale for large vessel occlusion detection in patients evaluated by in-hospital telestroke. These scales may be valid alternatives to the National Institutes of Health Stroke Scale examination in this setting.

Donation after circulatory death: A transplant cardiologist's take on neuroprognostication

Donation after circulatory death (DCD) is becoming increasingly utilized in heart transplantation and has the potential to further expand the donor pool. As transplant cardiologists gain more familiarity with DCD donor selection, there are many issues that lack consensus including how we incorporate the neurologic examination, how we measure functional warm ischemic time (fWIT), and what fWIT thresholds are acceptable. DCD donor selection calls for prognostication tools to help determine how quickly a donor may expire, and in current practice there is no standardization in how we make these predictions. Current scoring systems help to determine which donor may expire within a specified time window either require the temporary disconnection of ventilatory support or do not incorporate any neurologic examination or imaging. Moreover, the specified time windows differ from other DCD solid organ transplantation without standardization or strong scientific justification for these thresholds. In this perspective, we highlight the challenges faced by transplant cardiologists as they navigate the muddy waters of neuroprognostication in DCD cardiac donation. Given these difficulties, this is also a call to action for the creation of a more standardized approach to improve the DCD donor selection process for appropriate resource allocation and organ utilization.

Abstract WP37: Prehospital Stroke Scales Outperform National Institutes Of Health Stroke Scale In Predicting Large Vessel Occlusion In A Large Telestroke Network

Introduction: Prehospital telestroke is increasingly utilized in mobile stroke units and telemedicine-enabled ambulances for acute ischemic stroke (AIS). While the NIHSS remains the standard for telestroke assessment, simpler scales have been validated to help paramedics recognize large vessel occlusion (LVO) strokes but have not been evaluated in a traditional telestroke network. We aimed to determine the accuracy of common LVO scales in a large academic telestroke practice.

Methods: This retrospective study included all telestroke consults performed in a large academic telestroke network from 2019 to 2020. Patients were excluded if no NIHSS or vessel imaging was performed. We recorded presenting NIHSS, site of vessel occlusion, and discharge diagnosis. LVO was defined as an acute occlusion of the internal carotid artery and/or M1 middle cerebral artery. The NIHSS was used to calculate 7 LVO scales (RACE, C-STAT, FAST-ED, 3I-SS, PASS, VAN, and G-FAST). Diagnostic performance was assessed by calculating sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy using the established thresholds of each scale. These results were compared to NIHSS at thresholds of 6, 8, and 10. Area under curve (AUC) was calculated using c-statistics by treating scales as continuous variables.

Results: A total of 625 patients were included, 373/625 (59.7%) of which were diagnosed with AIS at discharge. LVO was identified in 78/625 (12.5%) patients. VAN was the most sensitive prehospital stroke scale (83.3%), whereas 3I-SS ≥ 4 was the most specific (95.2%). Both the RACE and FAST-ED scales demonstrated superior accuracy and AUC compared to the NIHSS (Table 1).

Conclusions: To our knowledge, this is the first study assessing LVO scale accuracy in a large telestroke network. As use of prehospital telestroke grows, this study highlights several scales that may allow for faster prehospital triage decisions without sacrificing accuracy.

Abstract TP45: Demonstration Of High Diagnostic Accuracy Of Cerebral Ischemia In A Large Academic Hub And Spoke Telestroke Network

Introduction: Telestroke facilitates emergent assessment of patients with suspected acute ischemic stroke (AIS) to identify candidates for acute interventions. The diagnostic accuracy of the telestroke consultation of a large academic hub and spoke telemedicine network has yet to be investigated. The goal of our study is to determine the diagnostic accuracy of the initial telestroke consultation.

Methods: This is an IRB-exempt retrospective study including all patients evaluated for cerebral ischemia via video telestroke consultation in a large academic hub and spoke telemedicine network from 2019 to 2020. Detailed chart review was conducted to identify initial suspected diagnosis and final diagnosis. Cerebral ischemia was defined as AIS and transient ischemic attack (TIA). All other diagnoses were defined as stroke mimics. Data was organized into continuous and categorical variables. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, area under the curve (AUC) and likelihood ratio (LR+) for the initial telestroke consultation diagnosis were calculated while using the final diagnosis as the gold standard diagnosis.

Results: A total of 1043 patients met inclusion criteria. Final diagnosis of cerebral ischemia was made in 63.5% of all patients (539/1043 with AIS,123/1043 with TIA). Stroke mimic was diagnosed in 36.5% patients (381/1043). The sensitivity and specificity of telestroke evaluation for diagnosis of cerebral ischemia were 97.1% and 81.4%, respectively. PPV was 90.1%, and NPV was 94.2%. Overall diagnostic accuracy was 91.4% with a LR+ of 5.21 and AUC of 0.89. The most common stroke mimics were metabolic encephalopathy (13.7%, 52/381), migraine (10.8%, 41/381) and seizure (10.5%, 40/381).

Conclusions: This study highlights the high diagnostic accuracy of telestroke providers to diagnose cerebral ischemia and stroke mimic in a large academic hub and spoke network. Further research is needed to investigate methods to improve our diagnostic accuracy further, as well as explore the application of tele-neurology in the non-stroke setting.

Telestroke’s Role Through the COVID-19 Pandemic and Beyond

Purpose of review

The goal of this paper is to discuss the role and utilization of telestroke services through the COVID-19 pandemic and to suggest future directions to sustain and increase patients’ access to stroke expertise.

Recent findings

Telestroke is an innovative and effective tool that has been shown to improve access, quality of care, and outcomes of patients with acute stroke syndromes in resource-limited areas for the last two decades. The COVID-19 pandemic posed a significant challenge and strained healthcare systems worldwide, but it created novel and unique opportunities to expand and increase the utilization of telehealth and telestroke services to deliver personalized healthcare across the continuum of stroke care outside of traditional settings. This rapid and widespread increase in telestroke use was facilitated by the removal of many legislative and regulatory barriers which have limited patients’ access to stroke expertise for many years.

Summary

As the public health emergency ends, there exists a unique opportunity to optimize and expand upon the pandemic-related rapid growth of telestroke care. Optimal utilization of telehealth and telestroke services will depend on maintaining and improving required infrastructure, laws, and regulations, particularly those governing reimbursement and licensing.

Influence of Platelet Count on Procedure-Related Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare outcomes between patients who underwent mechanical thrombectomy for large vessel occlusion based on platelet count: low versus normal.

METHODS

Three studies were included with a pooled cohort of 1125 patients. Data points were collected and pooled by meta-analysis of proportions via a logit transformation to provide a summary statistic. Both fixed-effect and random-effects models were recruited for the analysis. In this meta-analysis, risk of developing symptomatic intracranial hemorrhage, unfavorable clinical outcomes (modified Rankin Scale score >3), and mortality of patients with low platelet counts were compared with patients with normal platelet counts according to the criteria for inclusion used by each study.

RESULTS

Of patients, 50 (4.7%) had low platelet count, and 1075 (95.3%) had normal platelet count. Patients in the low platelet count group had a substantially higher risk of mortality (risk ratio 1.93, 95% confidence interval 1.43-2.60, P < 0.0001, I² = 0%), but no differences in clinical outcomes (risk ratio 0.66, 95% confidence interval 0.40-1.11, P = 0.12, I² = 0%) or symptomatic intracranial hemorrhage (risk ratio 2.03, 95% confidence interval 0.87-4.70, P = 0.10, I² = 15%) were noted.

CONCLUSIONS

Patients with low platelet counts had increased mortality compared with patients with normal platelet counts following mechanical thrombectomy for large vessel occlusion.

Telemedicine-enabled ambulances and mobile stroke units for prehospital stroke management

The recognition and management of stroke in the prehospital setting has become increasingly important to improve patient outcomes. Several strategies to advance prehospital stroke care have been developed, including the mobile stroke unit and the telemedicine-enabled ambulance-or "mini-MSU." These strategies both incorporate ambulance-based audio-visual telemedicine evaluation with a vascular neurologist to facilitate faster treatment but differ in several areas including upfront and recurring costs, scalability or growth potential, ability to integrate into existing emergency medical services systems, and interoperability across multiple specialties or conditions. While both the mobile stroke unit and mini-mobile stroke unit model are valid approaches to improve stroke care, the authors aim to compare these models based on costs, scalability, integration, and interoperability in order to guide our prehospital leaders to find the best solutions for their communities.

Acute Epstein-Barr virus infection presenting as Guillain-Barre syndrome

An 18-year-old man presented with 5-days of a lower extremity rash, sore throat, rapidly progressive bilateral facial numbness and paresthesias in his distal extremities. His neurological examination acutely deteriorated to include moderate bilateral facial weakness in a lower motor neuron pattern, mild flaccid dysarthria, mild bilateral interossei weakness, and diffuse hyporeflexia. In addition to neurological examination, EMG results of acute demyelinating polyradiculoneuropathy were suggestive of Guillain-Barre Syndrome (GBS). Infectious laboratory testing demonstrated acute infection of Epstein-Barr Virus (EBV) with relatively low EBV DNA quantitative values. The patient subsequently developed fever and cervical lymphadenopathy during his hospital course. Contrasting typical GBS, which presents weeks after an acute infection, the patient's presenting symptom of EBV infection was GBS. GBS as a presenting symptom of EBV has not previously been described. This case may represent a unique mechanism for the pathogenesis of GBS in acute infections as opposed to the traditional post-infectious antibody-mediated process.

Reliability of Field Assessment Stroke Triage for Emergency Destination Scale Use by Paramedics: Mobile Stroke Unit First-Year Experience

[Figure: see text].

Vascular Spinal Cord Disorders

Vascular disorders of the spinal cord are uncommon yet under-recognized causes of myelopathy. Etiologies can be predominantly categorized into clinical and radiographic presentations of arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage. While vascular myelopathies often produce significant morbidity, recent advances in the understanding and recognition of these disorders should continue to expedite diagnosis and proper management, and ideally improve patient outcomes. This article comprehensively reviews relevant spinal cord vascular anatomy, clinical features, radiographic findings, treatment, and prognosis of vascular disorders of the spinal cord.

Safety of Ticagrelor in Moderate and Severe Acute Ischemic Stroke: A Single-Center Retrospective Review

OBJECTIVES

Ticagrelor may be superior to aspirin after minor ischemic stroke or TIA, particularly in patients with symptomatic atherosclerotic disease. However, there may be an increased risk of intracerebral hemorrhage in patients with moderate to severe ischemic stroke, and ticagrelor has not been studied in this patient population. Therefore, we sought to evaluate the safety of ticagrelor after moderate or severe ischemic stroke.

MATERIALS AND METHODS

Retrospective chart review of all patients admitted with acute ischemic stroke and NIHSS 6 or greater who were discharged on ticagrelor between January 2016 and December 2019. Patients who underwent angioplasty, stenting or carotid revascularization during the hospitalization were excluded.

RESULTS

Of 183 patients discharged on ticagrelor, 61 patients were included. Median age was 61 (IQR 52-68); 33 (54%) patients were men. Median NIHSS was 11 (IQR 8-15). Fourteen (23%) patients received IV alteplase and 35 (57%) patients received mechanical thrombectomy. Stroke mechanism was large artery atherosclerosis in 53 (87%) of patients, of which 40 (71%) were deemed intracranial atherosclerosis. Final infarct volume was greater than 10 mL in 32 (52%) patients. Follow-up information was available for 53 (87%) patients; median length of follow-up was 3 (IQR 2-6) months. Six (10%) patients experienced recurrent ischemic stroke. No patients experienced symptomatic intracerebral hemorrhage after initiation of ticagrelor. One (2%) patient experienced major bleeding.

CONCLUSIONS

This study provides preliminary evidence supporting the potential safety of ticagrelor following moderate or severe acute ischemic stroke. These findings support the need for future prospective studies.

Abstract P556: Emergent Use of Ticagrelor and Glycoprotein IIbIIIa in Neuroendovascular Interventions

Introduction: Evidence regarding the optimal acute antiplatelet strategies in emergent endovascular therapies is scarce, and practices varies institutionally. Ticagrelor, a P2Y3B inhibitor with a lower incidence of resistance, may be effective in achieving rapid platelet inhibition. We explore the safety and efficacy of emergent Ticagrelor use in patient undergoing neurointerventions.

Methods: We reviewed our database for all consecutive patients from 2016 to 2019 who received emergent administration of Ticagrelor (within 30 minutes before or after) for neuro-interventional procedures. The primary outcome measure was the incidence of major systemic hemorrhages including symptomatic intracranial hemorrhage as well as intraprocedural and post-procedural thrombotic events.

Results: 81 patients were analyzed (Mean age 62±11, 70% male, 73 undergoing interventions for ischemic strokes, 8 aneurysm patients undergoing embolization). Twenty (24.7%) patients received Ticagrelor pre-puncture, 28 (35%) during and 33 (41%) after closure. Median PRU achieved in 43 patients after excluding for concomitant use of GPIIbIIIa use was 54 [36-111]. Major bleeding occurred in 7/81 patients (9.2%) - 4 gastrointestinal bleeding and 3 symptomatic ICH. Eleven (14%) patients experienced intraprocedural occlusions. Five (6.2%) cases were complicated by post-procedural occlusions while on Ticagrelor, two of which were asymptomatic. Pre-procedural Ticagrelor was associated with less frequent administration of subsequent GPIIbIIIa (OR = 0.15, 95% CI (0.03-0.64), p=0.01), as well as shorter procedure duration (Spearman’s rho 0.409, p =0.001). The use of GPIIbIIIa plus Ticagrelor was associated with increased bleeding complications (0% vs. 14%; p =0.04) than in patients receiving Ticagrelor only. Bleeding was an independently predictive risk factor for death by 3 months (OR 7.18, 95% CI (1.33-38.8, p=0.02 or 43% vs. 9.5%; p=0.04)

Conclusion: Early and emergent use of Ticagrelor, prior to endovascular procedure as early as within 30 minutes, may obviate the need for administration of GPIIbIIIa. Combined use of GPIIbIIa antithrombotics with Ticagrelor was associated with hemorrhagic complications, which could contribute to increased mortality.

Abstract P25: Safety of Ticagrelor in Moderate to Severe Acute Ischemic Stroke: A Single-Center Retrospective Review

Introduction: Ticagrelor with aspirin has been recently shown to reduce the risk of stroke or death compared to aspirin alone in patients with high risk TIAs and mild strokes. However, this benefit is offset by increased risk of severe bleeding. We sought to evaluate the safety of ticagrelor in patients with moderate to severe ischemic stroke.

Methods: This was a retrospective cohort study of adults discharged on ticagrelor after presenting with acute ischemic stroke and NIHSS > 5 from January 2016 to December 2019 at a large, urban, academic comprehensive stroke center. Patients were excluded if they underwent carotid or intracranial angioplasty and/or stenting, or carotid endarterectomy during admission. Baseline clinical characteristics, imaging, and outcomes were reviewed. Data was organized into continuous and categorical variables.

Results: Sixty-one patients met inclusion and exclusion criteria. Median age was 61 (IQR, 52-68) years; 33 (54%) were men, and 33 (54%) were African American. Median NIHSS was 11 (IQR, 8-15). Fourteen (23%) patients received IV Alteplase and 35 (57%) patients underwent mechanical thrombectomy. Five (8%) patients received both IV Alteplase and mechanical thrombectomy. Median ticagrelor start date was hospital day 1 (IQR, 0-3). Large artery atherosclerosis was presumed etiology in 53 (87%) patients. No patients experienced neurologic worsening, recurrent stroke, sICH, or major bleeding during inpatient stay. Sixty (98%) patients were on aspirin and ticagrelor at discharge. Follow-up information was available for 53 (87%) patients for a median duration of 3 (IQR, 2-6) months. Following discharge, 3 (5%) patients experienced recurrent ischemic stroke despite being compliant. One (2%) patient experienced major bleeding—gastrointestinal hemorrhage requiring transfusion—two months after hospital discharge.

Conclusions: This study highlights the potential expanding role for ticagrelor in secondary stroke prevention in patients with moderate to severe stroke. Early ticagrelor use did not result in sICH during inpatient stay—and only 1 major bleeding event on follow-up—in our cohort. While further research in this area is needed, these findings present an exciting opportunity for future prospective studies.

Spinal cord transient ischemic attack: Insights from a series of spontaneous spinal cord infarction

Objective

To define the prevalence and characteristics of spinal cord transient ischemic attack (sTIA) in a large retrospective series of patients who met diagnostic criteria for spontaneous spinal cord infarction (SCI).

Methods

An institution-based search tool was used to identify patients evaluated at the Mayo Clinic in Rochester, MN, from 1997 to 2017 with spontaneous SCI (n = 133). Cases were subsequently reviewed for transient myelopathic symptoms preceding infarction that were suspected ischemic in nature. We performed a descriptive analysis of patients with sTIA before SCI.

Results

Of 133 patients with a diagnosis of spontaneous SCI, we identified 4 patients (3%) who experienced sTIA before SCI. The median age at presentation was 61.5 years (range 46-75 years), 2 (50%) were women, and 3 (75%) had traditional vascular risk factors. Localization was cervical cord in 2 cases (50%) and thoracic cord in 2 cases (50%); all patients developed SCI in the same distribution as their preceding sTIA symptoms. All patients experienced recurrent sTIA before SCI. Symptoms ranged from seconds to a few minutes before returning to baseline. No patients had pain as a feature of sTIA.

Conclusions

sTIAs are possible but rare in patients who subsequently have a SCI. Clinical features are similar to those of SCI, with rapid onset of severe myelopathic deficits, followed by prompt resolution. Vascular risk factors are common in these patients. Thus, recognition of a sTIA may represent a valuable opportunity for vascular risk factor modification and stroke prevention. However, given the rarity, physicians should explore other possible explanations when sTIA is considered.

Safety and efficacy of ticagrelor as single antiplatelet therapy in prevention of thromboembolic complications associated with the Pipeline Embolization Device (PED): multicenter experience

BACKGROUND

Flow diversion (FD) is a common treatment modality for complex intracranial aneurysms. A major concern regarding the use of FD is thromboembolic events (TEE). There is debate surrounding the optimal antiplatelet regimen to prevent TEE. We aim to evaluate the safety and efficacy of ticagrelor as a single antiplatelet therapy (SAPT) for the prevention of TEE following FD for complex aneurysm treatment.

METHODS

A retrospective review of a prospectively maintained neuroendovascular database at three endovascular centers was performed. Patients were included if they had an intracranial aneurysm that was treated with FD between January 2018 and September 2019 and were treated with ticagrelor as SAPT. Primary outcomes included early (within 72 hours post-procedure) and late (within 6 months) ischemic events.

RESULTS

A total of 24 patients (mean age 47.7 years) with 36 aneurysms were eligible for analysis, including 15 (62.5%) females. 14 (58.3%) patients presented with subarachnoid hemorrhage. 35 aneurysms arose from the anterior circulation and 1 from the posterior circulation. 23 aneurysms had a saccular morphology, whereas 7 were fusiform and 6 were blister. For the treatment of all 36 aneurysms, 30 procedures were performed with 32 FD devices. Procedural in-stent thrombosis occurred in 2 cases and was treated with intra-arterial tirofiban without complications. Aneurysm re-bleeding was reported in 1 (4.2%) patient. There were no reported early or late TEE. Three patients discontinued ticagrelor due to systemic side effects.

CONCLUSION

Ticagrelor is a safe and effective SAPT for the prevention of TEE after FD. Large multicenter prospective studies are warranted to validate our findings.

The Ottawa SAH search algorithms: protocol for a multi- centre validation study of primary subarachnoid hemorrhage prediction models using health administrative data (the SAHepi prediction study protocol)

Background

Conducting prospective epidemiological studies of hospitalized patients with rare diseases like primary subarachnoid hemorrhage (pSAH) are difficult due to time and budgetary constraints. Routinely collected administrative data could remove these barriers. We derived and validated 3 algorithms to identify hospitalized patients with a high probability of pSAH using administrative data. We aim to externally validate their performance in four hospitals across Canada.

Methods

Eligible patients include those ≥18 years of age admitted to these centres from January 1, 2012 to December 31, 2013. We will include patients whose discharge abstracts contain predictive variables identified in the models (ICD-10-CA diagnostic codes I60** (subarachnoid hemorrhage), I61** (intracranial hemorrhage), 162** (other nontrauma intracranial hemorrhage), I67** (other cerebrovascular disease), S06** (intracranial injury), G97 (other postprocedural nervous system disorder) and CCI procedural codes 1JW51 (occlusion of intracranial vessels), 1JE51 (carotid artery inclusion), 3JW10 (intracranial vessel imaging), 3FY20 (CT scan (soft tissue of neck)), and 3OT20 (CT scan (abdominal cavity)). The algorithms will be applied to each patient and the diagnosis confirmed via chart review. We will assess each model’s sensitivity, specificity, negative and positive predictive value across the sites.

Discussion

Validating the Ottawa SAH Prediction Algorithms will provide a way to accurately identify large SAH cohorts, thereby furthering research and altering care.

Focal Epilepsy in a Teenager With Facial Atrophy and Hair Loss

There is increasing evidence to demonstrate that Parry-Romberg syndrome and linear scleroderma en coup de sabre are both forms of linear scleroderma, representing localized autoimmune conditions affecting the skin, eyes, brain, and surrounding tissues. We present a case highlighting the clinical presentation of a 12-year-old boy with focal seizures and physical examination findings of facial atrophy and hair loss. This article reviews the literature related to the presentation, epidemiology, diagnosis, and treatment of Parry-Romberg syndrome and linear scleroderma en coupe de sabre with focus on the significant correlation with neurologic disease, particularly seizures.

Multiple cranial neuropathies as a presentation of spontaneous internal carotid artery dissection: A case report and literature review

Cervical artery dissection is an underrecognized cause of lower cranial neuropathies and diagnosis can remain elusive if not properly investigated. We present a case of an internal carotid artery dissection that was initially missed in a 48-year-old man who presented with subacute-onset of dysarthria, dysphagia, and unilateral tongue weakness. Knowledge of the most common presenting symptoms, relevant neuroanatomy, and neuroimaging techniques is essential to avoid misdiagnosis. Pseudoaneurysm formation from subadventitial carotid artery dissection may result in compressive neuropathies of cranial nerves IX, X, XI, and XII without associated cerebral ischemia. The absence of intraluminal narrowing on CT or MR angiography should not dissuade the clinician; T1-weighted axial cervical MRI with fat-saturation provides the highest sensitivity and specificity to identify these lesions.

Hyperkinetic transient ischemic attacks preceding deep ganglionic infarction in a patient with a treated parasellar chondrosarcoma

A 44-year-old right-handed female with a past medical history of parasellar chondrosarcoma status post-surgical debulking and proton beam therapy (70 Gy) three years prior to presentation experienced several hours of brief, repetitive episodes of transient hemiballism and dystonia; this was followed by abrupt onset of fixed hemiparesis and dysarthria weeks later, ipsilateral to her prior hyperkinetic movements. She was found to have total occlusion of the right middle cerebral artery with focal stenosis of the proximal right A-1 segment of the anterior cerebral artery adjacent to the remnants of the chondrosarcoma. These focal areas of narrowing were attributed to accelerated atherosclerotic disease, an adverse effect of the radiotherapy used to treat her chondrosarcoma. As treatments improve and mean survival increases for intracranial malignancy, radiation-induced atherosclerotic disease with protean manifestations such as those presented in this case may be encountered more frequently.