Rabinstein, Alejandro A.

Background and purposeThe full spectrum of causes of convexal subarachnoid hemorrhage (cSAH) requires further investigation. Therefore, our objective was to describe the spectrum of clinical and imaging features of patients with non‐traumatic cSAH.MethodsA retrospective observational study of consecutive patients with non‐traumatic cSAH was performed at a tertiary referral center. The underlying cause of cSAH was characterized and clinical and imaging features that predict a specific etiology were identified. The frequency of future cSAH or intracerebral hemorrhage (ICH) was determined.ResultsIn all, 88 patients [median age 64 years (range 25–85)] with non‐traumatic cSAH were identified. The most common causes were reversible cerebral vasoconstriction syndrome (RCVS) (26, 29.5%), cerebral amyloid angiopathy (CAA) (23, 26.1%), indeterminate (14, 15.9%) and endocarditis (9, 10.2%). CAA patients commonly presented at an older age than RCVS patients (75 years versus 51 years, P < 0.0001). Thirteen patients (14.7%) had recurrent cSAH, and 12 patients (13.6%) had a subsequent ICH. However, the risk was high amongst those with CAA compared to those caused by RCVS, with recurrent cSAH in 39.1% and subsequent lobar ICH in 43.5% of CAA cases.ConclusionsOur study demonstrates the clinical diversity of cSAH. Older age, sensorimotor dysfunction and stereotyped spells suggest CAA as the underlying cause. Younger age and thunderclap headache predict RCVS. Yet, various other causes also need to be considered in the differential diagnosis.

Background and Purpose— Emerging evidence demonstrating the high sensitivity of early brain computed tomography (CT) brings into question the necessity of always performing lumbar puncture after a negative CT in the diagnosis of spontaneous subarachnoid hemorrhage (SAH). Our objective was to determine the sensitivity of brain CT using modern scanners (16-slice technology or greater) when performed within 6 hours of headache onset to exclude SAH in neurologically intact patients. Methods— After conducting a comprehensive literature search using Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus, we conducted a meta-analysis. We included original research studies of adults presenting with a history concerning for spontaneous SAH and who had noncontrast brain CT scan using a modern generation multidetector CT scanner within 6 hours of symptom onset. Our study adheres to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Results— A total of 882 titles were reviewed and 5 articles met inclusion criteria, including an estimated 8907 patients. Thirteen had a missed SAH (incidence 1.46 per 1000) on brain CTs within 6 hours. Overall sensitivity of the CT was 0.987 (95% confidence intervals, 0.971–0.994) and specificity was 0.999 (95% confidence intervals, 0.993–1.0). The pooled likelihood ratio of a negative CT was 0.010 (95% confidence intervals, 0.003–0.034). Conclusions— In patients presenting with thunderclap headache and normal neurological examination, normal brain CT within 6 hours of headache is extremely sensitive in ruling out aneurysmal SAH.

AbstractIntroductionThe objective of our study was to investigate cross‐sectional associations of atrial fibrillation with neuroimaging measures of cerebrovascular disease and Alzheimer's disease and their interactions with mild cognitive impairment (MCI).MethodsMagnetic resonance imaging scans of individuals from a population‐based study were analyzed for infarctions, total gray matter, and hippocampal and white matter hyperintensity volumes. A subsample underwent positron emission tomography imaging.ResultsAtrial fibrillation was associated with infarctions and lower total gray matter volume. Compared with subjects with no atrial fibrillation and no infarction, the odds ratio (95% confidence intervals) for MCI was 2.99 (1.57–5.70; P = .001) among participants with atrial fibrillation and infarction, 0.90 (0.45–1.80; P = .77) for atrial fibrillation and no infarction, and 1.50 (0.96–2.34; P = .08) for no atrial fibrillation and any infarction.DiscussionParticipants with both atrial fibrillation and infarction are more likely to have MCI than participants with either infarction or atrial fibrillation alone.

Objective In certain situations, severe forms of Guillain-Barré syndrome (GBS) show no response or continue to deteriorate after intravenous immunoglobulin (IVIg) infusion. It is unclear what the best treatment option would be in these circumstances.Method This is a case report on patients with severe axonal GBS in whom a second cycle of IVIg was used.Results Three patients on mechanical ventilation who presented axonal variants of GBS, with autonomic dysfunction, bulbar impairment and Erasmus score > 6, showed no improvement after IVIg infusion of 400 mg/kg/d for 5 days. After 6 weeks, we started a second cycle of IVIg using the same doses and regimen as in the previous one. On average, 5 days after the second infusion, all the patients were weaned off mechanical ventilation and showed resolution of their blood pressure and heart rate fluctuations.Conclusions A second cycle of IVIg may be an option for treating severe forms of GBS.

Background and purpose Many studies have suggested a relationship between the type of anesthesia provided during intra-arterial therapy for acute ischemic stroke and patient outcomes. Variability in blood pressure and hypotension have previously been identified as possible reasons for worse outcomes in acute stroke. Our aim was to investigate hemodynamic parameters and neurological outcomes of patients receiving either general anesthesia or conscious sedation for intra-arterial therapy of acute stroke. Methods We performed a retrospective review of patients undergoing intra-arterial therapy from December 2008 to March 2015. Demographic data, baseline National Institutes of Health Stroke Scale score, preoperative physiological variables, procedural details, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate, and modified Rankin Scale scores were recorded. Results 99 patients were included in the study, with 38 receiving general anesthesia and 61 receiving conscious sedation. Patients who received general anesthesia had a lower maximum SBP (p=0.02), minimum SBP (p<0.0001), minimum DBP (p<0.0001), and minimum MAP (p<0.0001). On multivariate analysis, general anesthesia was associated with lower minimum SBP (p=0.04), DBP (p=0.02), and MAP (p=0.007). Conscious sedation was associated with more favorable neurological outcomes (p=0.02). Patients with favorable neurological outcomes had a lower maximum variability in SBP (p=0.01) and MAP (p=0.03), as well as a higher minimum DBP (p=0.03). Conclusions Patients with acute ischemic stroke undergoing intra-arterial therapy with general anesthesia had lower minimum SBP, DBP, and MAP, greater fluctuations in blood pressure, and less favorable outcomes. More studies are needed to examine the implications of variable and reduced blood pressures and neurological outcomes.