Rabinstein, Alejandro A.

Objective: To assess the long-term outcomes of patients hospitalized with severe West Nile neuroinvasive disease. Design: Retrospective cohort. Setting: Patients admitted to a referral center (Saint Mary’s Hospital, Mayo Clinic). Participants: Twenty-six patients with West Nile neuroinvasive disease were identified by retrospective search of electronic database of Saint Mary’s Hospital from January 1999 to November 2016. Interventions: Retrospective electronic medical records review and prospective telephone follow-up. Measurements and Main Results: Functional disability and cognitive outcomes were evaluated with the modified Rankin Scale and the Telephone Interview for Cognitive Status scores. Data on the time that the patient returned home after the hospitalization for West Nile neuroinvasive disease and the time of return to work were also collected. We identified 26 patients (81% males), 59 ± 17 years old. After a median hospital stay of 14.5 days (3–126), four patients died and 90% of survivors had a modified Rankin Scale of 3–5. Two additional patients died, and 80% of survivors had a modified Rankin Scale of 0–2 after a median follow-up of 73 months (1–144). Seven patients had cognitive impairment, which was severe in two of them. The combination of encephalitis and acute flaccid paralysis at presentation was associated with lower likelihood of returning home within 1 month after discharge (p < 0.01). Patients who required mechanical ventilation were more likely to have a modified Rankin Scale of 3–5 at last follow-up (p = 0.03), less likely to return home within 1 month of discharge (p < 0.01), less likely to return to their jobs (p < 0.01), and showed a trend toward having cognitive impairment (p = 0.05). Conclusions: Despite having poor outcomes at discharge, most West Nile neuroinvasive disease survivors with severe early disability can recover functional independence in the long term, justifying aggressive support during the acute phase and extensive rehabilitation efforts.

Spontaneous intracranial hypotension (SIH) is an uncommon headache etiology, typically attributable to an unprovoked occult spinal CSF leak. Although frequently benign, serious complications may occur, including cerebral venous thrombosis (CVT). The objective of this study was to examine a highly complicated case of CVT attributable to SIH as a lens for understanding the heterogeneous literature on this rare complication, and to provide useful, evidence-based, preliminary clinical recommendations. A 43-year-old man presented with 1 week of headache, dizziness, and nausea, which precipitously evolved to hemiplegia. CT venography confirmed CVT, and therapeutic heparin was initiated. He suffered a generalized seizure due to left parietal hemorrhage, which subsequently expanded. He developed signs of mass effect and herniation, heparin was discontinued, and he was taken to the operating room for clot evacuation and external ventricular drain placement. Intraoperatively, the dura was deflated, suggesting underlying SIH. Ventral T-1 CSF leak was identified, which failed multiple epidural blood patches and required primary repair. The patient ultimately made a complete recovery. Systematic review identified 29 publications describing 36 cases of SIH-associated CVT. Among 31 patients for whom long-term neurological outcome was reported, 25 (81%) recovered completely. Underlying coagulopathy/risk factors were identified in 11 patients (31%). CVT is a rare and potentially lethal sequela occurring in 2% of SIH cases. Awareness of the condition is poor, risking morbid complications. Evaluation and treatment should be directed toward identification and treatment of occult CSF leaks. Encouragingly, good neurological outcomes can be achieved through vigilant multidisciplinary neurosurgical and neurocritical care.

Abstract BACKGROUND Increased body mass index (BMI) may be protective against cerebral ischemia in certain clinical contexts. OBJECTIVE To investigate whether increased BMI was associated with delayed cerebral ischemia (DCI) and subsequent infarction after aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed the clinical course of patients presenting to our institution for management of aSAH. Patient were segregated according to BMI< or ≥29.4, a value determined by Classification and Regression Tree analysis. Predictors of DCI and delayed infarction were identified using stepwise multivariate logistic regression analysis. RESULTS There were 161 patients included for analysis. Average BMI within our patient cohort was 28.9, with 67 patients presenting with a BMI of ≥29.4 on admission. DCI occurred in 50 patients (31.1%) and was complicated by delayed infarction in 15 patients (9.3%). On stepwise multivariate analysis, BMI ≥ 29.4 was independently associated with reduced likelihood of DCI (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.18-0.92) and delayed infarction (OR 0.13, 95% CI 0.02-0.61; P = .008). Increasing maximum flow velocity on transcranial Doppler ultrasound was independently associated with increased odds of both DCI (Unit OR 1.19, 95% CI 1.09-1.30; P < .001) and delayed infarction (Unit OR 1.31, 95% CI 1.13-1.56; P < .001), while intracerebral hemorrhage was independently associated with increased odds of delayed infarction (OR 6.99, 95% CI 1.82-30.25; P = .005). CONCLUSION We report an association between elevated BMI and reduced incidence of DCI and delayed infarction, suggesting a protective effect of increasing BMI on the risk of ischemic complications after aSAH.

BackgroundCarotid plaque imaging with MRI is becoming more commonplace, but practical challenges exist in performing plaque imaging with surface coils.PurposeTo compare the diagnostic performance of a carotid plaque MRI protocol using a standard neurovascular coil (Neurovascular Coil Protocol) to a higher‐resolution carotid plaque MRI using carotid surface coils (Surface Coil Protocol) in characterizing carotid plaque.Study TypeProspective study comparing two MR techniques in plaque characterization.PopulationThirty‐eight consecutive carotid artery disease patients.Field Strength/SequencePatients underwent 3T MRI using 1) a Neurovascular Coil Protocol including the following sequences: 3D‐FSE T1 pre/postcontrast and precontrast 3D IR‐FSPGR, and 2) a Surface Coil Protocol using standard multicontrast MRI sequences.AssessmentPlaque characteristics analyzed by two independent neuroradiologists included intraplaque hemorrhage (IPH), lipid‐rich necrotic‐core (LRNC), and thin/ruptured fibrous cap (TRFC).Statistical TestsDiagnostic performance of the Neurovascular Coil Protocol was compared to the Surface Coil Protocol reference standard using receiver‐operating curves.ResultsFor IPH, sensitivity, specificity, and area under the curve (AUC) of the Neurovascular Coil Protocol were 91.1% (95% confidence interval [CI] = 78.8–97.5%), 87.0% (95% CI = 66.4–97.2%), and 0.92, respectively. For LRNC without IPH sensitivity, specificity, and AUC were 73.3% (95% CI = 44.9–92.2%), 85.7% (95% CI = 67.3–96.0%), and 0.84, respectively. For TRFC, sensitivity, specificity, and AUC were 35.3% (95% CI = 14.2–61.7%), 97.6% (95% CI = 87.4–99.9%), and 0.66 respectively. Interobserver agreement for IPH, LRNC, and TRFC using the Neurovascular Coil Protocol were k = 0.87 (95% CI = 0.75–0.99), k = 0.54 (95% CI = 0.29–0.80), and k = 0.41 (95% CI = 0.08–0.74), respectively.Data ConclusionOur Neurovascular Coil Protocol has high sensitivity, specificity, and accuracy in identifying IPH and LRNC but is limited in assessment of TRFC.Level of Evidence: 1Technical Efficacy: Stage 2J. Magn. Reson. Imaging 2018;47:1264–1272.