Fugate, Jennifer E.

Background Resuming anticoagulation in patients with mechanical heart valves after intracranial hemorrhage presents a clinical dilemma. The optimal timing must balance the risk of thromboembolism against hemorrhagic expansion. Prior studies have addressed this issue, but most were limited by small sample sizes. This systematic review and meta‐analysis aimed to determine the optimal timing for anticoagulation resumption in this population. Methods We conducted a systematic review and meta‐analysis using PubMed, Embase, Web of Science, and Scopus from database inception to August 23, 2024. The target population included adults with intracranial hemorrhage who required anticoagulation for mechanical heart valves. Results Thirteen studies involving 788 patients were included: 12 retrospective and 1 prospective observational study. While off anticoagulation, 32 patients developed ischemic stroke, with a pooled event rate of 5.23% (95% CI, 3.80–7.20%) and negligible heterogeneity ( I 2 = 0%). The pooled average time to stroke was 8.08 days (95% CI, 1.99–14.18). After anticoagulation resumption, 73 patients experienced hemorrhagic recurrence, corresponding to a pooled event rate of 10.95%, with nonsignificant heterogeneity ( I 2 = 40.4%). Conclusions Withholding anticoagulation for up to 7 days after intracranial hemorrhage in patients with mechanical heart valves appears relatively safe. Hemorrhagic recurrence after resumption was more common than ischemic stroke during interruption. However, the included studies were observational and carried serious or critical risk of bias. Prospective multicenter studies, and ideally randomized trials, are needed to provide more definitive evidence.

Dermatoneuro syndrome (DNS) is a rare diagnosis of exclusion characterised by fever, altered mental status and seizures in patients with scleromyxoedema. We present a complex case of a patient presenting with a fever, coma, seizures, rigidity and deep T2 fluid-attenuated inversion recovery hyperintensities in the context of both scleromyxoedema and influenza A with extensive, negative infectious workup. This case highlights the shared clinical features of DNS and influenza-associated encephalopathy, the latter being the eventual diagnosis for our patient. We review the DNS literature focusing on presentation, adequacy of investigation, treatment and prognosis. Finally, we provide an initial workup for patients with suspected DNS, including nasopharyngeal influenza PCR.

Introduction: Posterior reversible encephalopathy syndrome (PRES) has been defined based on classic risk factors, clinical characteristics, and evidence of reversibility. Radiographic evidence of vasogenic edema, which is best seen on MRI, is considered a cornerstone of the diagnosis. Yet, severity of clinical presentation does not correlate with extent of edema on MRI. We sought to explore whether PRES can present with negative MRI by comparing clinical features between cases of PRES with classic MRI findings and cases of hypertensive encephalopathy without MRI changes. Methods: Patients diagnosed with hypertensive encephalopathy from August 1, 2008 to December 31, 2017 were identified retrospectively and matched by age (+/- 5 years) and sex in a 2:1 ratio to patients retrospectively identified as having PRES from January 1 st , 2002 to November 30 th , 2017. All patients had undergone MRI, and images were reviewed. A detailed review of clinical information from the medical records was performed and included analysis of presenting symptoms, risk factors, and medical history. Results: We identified 16 cases of hypertensive encephalopathy and 32 age and sex matched controls with PRES on MRI. There were no statistically significant differences in the odds of presentation with headache (OR=1.372, 95% CI [0.458, 4.106]), encephalopathy (OR=2.303, 95% CI [0.433, 12.236]), visual disturbance (OR= 0.826, 95% CI [0.185, 3.697]), or focal neurologic deficit (OR=4.000, 95% CI [0.767, 20.872]). Seizures were more common at presentation in patients with typical PRES with vasogenic edema (OR=0.082, 95% CI [0.010, 0.664]). There was no significant difference in baseline creatine (OR= 0.874, 95% CI [0.424, 1.799]), admission creatine (OR= 1.215, 95% CI [0.819, 1.803]), or odds of acute kidney injury (OR=2.90, 95% CI [0.679, 12.449]). There were no statistically significant differences in the odds of having a past medical history of malignancy (OR= 0.295, 95% CI [0.076, 1.152]), transplant (OR= 3.347, 95% CI [0.594, 18.880]), or autoimmune disease (OR= 0.400, 95% CI [0.104, 1.532]). Resolution to baseline was the norm and occurred similarly in both groups. Conclusions: Most presenting symptoms and key risk factors were not significantly different between cases of hypertensive encephalopathy without vasogenic edema on MRI and typical PRES, arguing that the diagnosis of PRES, at least in the setting of acute severe hypertension, should not depend on MRI confirmation.