Overlapping Autoimmune Neurological Syndrome: A Case Report of Triple-Positive Antibody

The presentation of several autoimmune neurological disorders in a single patient is rare and often debilitating. However, early diagnosis and efficacious treatment can lead to a significant recovery. Here, we present an interesting case of a triple antibody-positive autoimmune neurological syndrome patient who manifested the clinical features of neuromyelitis optica (NMO) spectrum disorder (NMOSD), N-methyl-D-aspartate (NMDA) receptor (NMDAR) encephalitis, and myasthenia gravis (MG). Hence, the patient manifested both central and peripheral nervous system immune-mediated neurological syndromes. A middle-aged female with a history of seropositive aquaporin-4 (AQP4) NMOSD on mycophenolate 1 g twice daily presented with severe fatigue and right eye ptosis (three months since NMOSD diagnosis) and tested positive for acetylcholine receptor (AchR) binding antibody, consistent with MG. Six months after the patient\u27s NMOSD diagnosis, she began to experience subacute progressive cognitive decline, behavioral changes, imbalance, anxiety/panic attacks, and paranoid delusions. NMDAR encephalitis was suspected, and she tested positive for cerebrospinal fluid NMDAR antibodies. After treatment with steroids failed, she was given two doses of rituximab 1 g, two weeks apart, and reported improvement in her symptoms shortly after the second dose

Behavior of Structural Concrete Frames with Hybrid Reinforcement under Cyclic Loading

A substantial amount of work was carried out on the use of fiber-reinforced polymer (FRP) in reinforcing concrete structural elements, which demonstrated considerable inelasticity or deformity through monotonous and fatigue loads. Even so, the action of FRP bars in FRP-RC columns and frame structures has not yet been studied during reversed cyclic loading. In this research, reversed cyclic loading was conducted on three beam-column joint models using the finite element method with ANSYS software. The first model was for a joint designed with steel rebar for both the longitudinal reinforcement and stirrups. Glass fiber reinforced polymer (GFRP) rebar was used to reinforced the second joint model for both longitudinal reinforcement and steel stirrups, and the third joint model was designed with hybrid steel/GFRP reinforcement for the longitudinal reinforcement and steel stirrups. The performance of the three models under reversed cyclic loading, such as load vs. story drift and energy dissipation capacity, were compared. The GFRP-reinforced model displayed a predominantly elastic activity up to failure. Although its energy dissipation was weak, its performance in terms of total storey drift demand was satisfactory

Mechanical Thrombectomy for Acute Ischemic Stroke in Metastatic Cancer Patients: A Nationwide Cross-Sectional Analysis

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) is the standard treatment for large vessel occlusion (LVO) acute ischemic stroke. Patients with active malignancy have an increased risk of stroke but were excluded from MT trials. METHODS: We searched the National Readmission Database for LVO patients treated with MT between 2016-2018 and compared the characteristics and outcomes of cancer-free patients to those with metastatic cancer (MC). Primary outcomes were all-cause in-hospital mortality and favorable outcome, defined as a routine discharge to home (regardless of whether home services were provided or not). Multivariate regression was used to adjust for confounders. RESULTS: Of 40,537 LVO patients treated with MT, 933 (2.3%) had MC diagnosis. Compared to cancer-free patients, MC patients were similar in age and stroke severity but had greater overall disease severity. Hospital complications that occurred more frequently in MC included pneumonia, sepsis, acute coronary syndrome, deep vein thrombosis, and pulmonary embolism (P\u3c0.001). Patients with MC had similar rates of intracerebral hemorrhage (20% vs. 21%) but were less likely to receive tissue plasminogen activator (13% vs. 23%, P\u3c0.001). In unadjusted analysis, MC patients as compared to cancer-free patients had a higher in-hospital mortality rate and were less likely to be discharged to home (36% vs. 42%, P=0.014). On multivariate regression adjusting for confounders, mortality was the only outcome that was significantly higher in the MC group than in the cancerfree group (P\u3c0.001). CONCLUSION: LVO patients with MC have higher mortality and more infectious and thrombotic complications than cancer-free patients. MT nonetheless can result in survival with good outcome in slightly over one-third of patients

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

BACKGROUND: COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers. METHODS: in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups. RESULTS: of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods (p \u3c0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations (p \u3c0.001), and transfers from outside facilities (p = 0.015). CONCLUSION: a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic

Intravenous tPA for Acute Ischemic Stroke in Patients with COVID-19

BACKGROUND/PURPOSE: Coronavirus disease 2019 (COVID-19) is associated with increased risk of acute ischemic stroke (AIS), however, there is a paucity of data regarding outcomes after administration of intravenous tissue plasminogen activator (IV tPA) for stroke in patients with COVID-19. METHODS: We present a multicenter case series from 9 centers in the United States of patients with acute neurological deficits consistent with AIS and COVID-19 who were treated with IV tPA. RESULTS: We identified 13 patients (mean age 62 (±9.8) years, 9 (69.2%) male). All received IV tPA and 3 cases also underwent mechanical thrombectomy. All patients had systemic symptoms consistent with COVID-19 at the time of admission: fever (5 patients), cough (7 patients), and dyspnea (8 patients). The median admission NIH stroke scale (NIHSS) score was 14.5 (range 3-26) and most patients (61.5%) improved at follow up (median NIHSS score 7.5, range 0-25). No systemic or symptomatic intracranial hemorrhages were seen. Stroke mechanisms included cardioembolic (3 patients), large artery atherosclerosis (2 patients), small vessel disease (1 patient), embolic stroke of undetermined source (3 patients), and cryptogenic with incomplete investigation (1 patient). Three patients were determined to have transient ischemic attacks or aborted strokes. Two out of 12 (16.6%) patients had elevated fibrinogen levels on admission (mean 262.2 ± 87.5 mg/dl), and 7 out of 11 (63.6%) patients had an elevated D-dimer level (mean 4284.6 ±3368.9 ng/ml). CONCLUSIONS: IV tPA may be safe and efficacious in COVID-19, but larger studies are needed to validate these results

Repeated Mechanical Endovascular Thrombectomy for Recurrent Large Vessel Occlusion: A Multicenter Experience

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) is now the standard of care for large vessel occlusion (LVO) stroke. However, little is known about the frequency and outcomes of repeat MT (rMT) for patients with recurrent LVO. METHODS: This is a retrospective multicenter cohort of patients who underwent rMT at 6 tertiary institutions in the United States between March 2016 and March 2020. Procedural, imaging, and outcome data were evaluated. Outcome at discharge was evaluated using the modified Rankin Scale. RESULTS: Of 3059 patients treated with MT during the study period, 56 (1.8%) underwent at least 1 rMT. Fifty-four (96%) patients were analyzed; median age was 64 years. The median time interval between index MT and rMT was 2 days; 35 of 54 patients (65%) experienced recurrent LVO during the index hospitalization. The mechanism of stroke was cardioembolism in 30 patients (56%), intracranial atherosclerosis in 4 patients (7%), extracranial atherosclerosis in 2 patients (4%), and other causes in 18 patients (33%). A final TICI recanalization score of 2b or 3 was achieved in all 54 patients during index MT (100%) and in 51 of 54 patients (94%) during rMT. Thirty-two of 54 patients (59%) experienced recurrent LVO of a previously treated artery, mostly the pretreated left MCA (23 patients, 73%). Fifty of the 54 patients (93%) had a documented discharge modified Rankin Scale after rMT: 15 (30%) had minimal or no disability (modified Rankin Scale score ≤2), 25 (50%) had moderate to severe disability (modified Rankin Scale score 3-5), and 10 (20%) died. CONCLUSIONS: Almost 2% of patients treated with MT experience recurrent LVO, usually of a previously treated artery during the same hospitalization. Repeat MT seems to be safe and effective for attaining vessel recanalization, and good outcome can be expected in 30% of patients

Abstract Number ‐ 268: Sarcoid Induced Posterior Circulation Abnormality With Recurrent Ischemic Strokes

Introduction The estimated incidence of Neurosarcoidosis is ∼5‐15%. Most of these cases involve anterior circulation. Here we are presenting a case of recurrent posterior circulation ischemic stroke in a patient with neurosarcoidosis. Methods A 41‐year‐old Male had biopsy proven sarcoidosis diagnosed in 2012 with pulmonary involvement. He was on chronic low dose Corticosteroid. In 2014, he presented with right pontine ischemic infarction causing left‐sided hemiplegia. He underwent extensive workup including conventional angiogram that showed irregular intracranial left vertebral artery with mild narrowing distal to posterior inferior cerebellar artery (PICA) and mild dilatation proximal to basilar artery (Image on the top). He was started on Aspirin 81 mg. In 2021, he had a right inferior cerebellar peduncle infarction with repeat angiogram showing abnormal dysplastic dilatation of the left vertebral artery at V4 segment and the top of basilar artery that has progressed since 2014 (image on the bottom). Workup showed that he was Aspirin non‐responder and has been switched to Clopidogrel. Results The most common presentation of neurosarcoidosis is cranial neuropathy, mostly facial nerve. Ischemic stroke is one of the uncommon presentation of neurosarcoidosis. The likely mechanism could begranulomatous invasion of the blood vessel wall with vasculitic disruption of the media and internal elastic lamina. Conclusions To our knowledge, this is a rare case of neurosarcoidosis progressively affecting posterior circulation causing recurrent stroke

Abstract 1122‐000032: Spinal Cord Infarction a Young Patient with a Hypoplastic Vertebral Artery

Introduction: Rare presentation of disease processes is absolutely intriguing to the human mind. Spinal cord infarction is abundantly reported to be secondary to cardiological procedures, patients carrying multiple vascular risk factors and vertebral artery dissections. But for it to happen in a patient who is young, relatively healthy and without vascular risk factors is quite interesting. Herein, we present the case of a patient presented with bilateral upper extremity weakness, who has a hypoplastic right vertebral artery that has coincided with him being a professional gamer with exerting compression from video‐gaming posturing of “forward leaning with neck hyperextension”, resulting in cervical spinal cord infarction. Methods: Case report Results: Vertebral artery dissection was excluded by CTA and MRA. our hypothesis was that the patient is a professional gamer and his posture of leaning forward and neck hyper‐extension had a role in inducing his spinal cord infarction given the fact of him having a hypoplastic right vertebral artery. Conclusions: Vertebral artery disease is a well‐recognized cause of ischemia in the posterior cerebral circulation. Recently, however, cervical cord infarction, albeit being extremely rare, has been increasingly reported as a complication of vertebral artery diseases such as dissection. Awareness must be raised that such condition can also happen in the young population due to compression of the vertebral arteries, especially when one is hypoplastic

Abstract Number ‐ 228: Two Cases of Vertebrobasilar Dolichoectasia +/‐ Obstructive Hydrocephalus

Introduction Dolichoectasia; “dolichos'' and “ectasia” respectively meaning elongation and distention of blood vessels is a process by which arteries undergo deterioration of the tunica intima or tunica media, resulting in smooth muscle atrophy.1 It can be atherosclerotic, non‐atherosclerotic, and dissection‐related. Prolonged hypertension resulting in breakdown and remodeling of collagen‐elastin meshwork produces the atherosclerotic subtype, though hyperlipidemia also plays a role. The incidence is approximately 3%, higher in males.2 Vessels commonly affected by dolichoectasia are in the vertebrobasilar system but the internal carotid arteries are also at risk. Vertebrobasilar dolichoectasia (VBDE) is radiographically defined by basilar artery diameter > 4.5 mm, though it is sometimes overlooked due to healthy variations in basilar tortuosity and diameter. Smoker’s criteria includes artery diameter, laterality, and bifurcation height.3 Neurovascular compression often occurs, but high‐risk complications of VBDE such as hemorrhagic or ischemic stroke, TIA, brainstem compression, hydrocephalus, or subarachnoid hemorrhage are also possible.4 We present two cases of ventriculomegaly in the setting of VBDE. Methods Case Report Results Case #1: A 40 year‐old man with history of hypertension, gout, anal fissures, and bicuspid aortic valve presented to the hospital for intermittent visual obscuration for 2 weeks. He described it as a “Polaroid picture: starting dark and slowly developing” featuring positional exacerbation with Valsalva, leaning forward, and laying flat. Examination revealed bilateral papilledema, right eye ptosis, and right 6th nerve palsy. CT head showed hydrocephalus. CTA and CTV were negative. MRI brain with contrast showed dilated lateral ventricles (left > right) and anterior third ventricle lacking significant transependymal CSF flow. The distal basilar was tortuous extending towards the mid‐portion of the third ventricle (Figure 1). A precipitating factor was thought to be an epidural for anal fissure surgery 2 months prior. Initially treated with acetazolamide, the patient later underwent endoscopic third ventriculostomy (ETV). One‐year follow‐up showed significant improvement of papilledema with minimal residual visual field deficits. Case #2: A 71 year‐old man with history of atrial fibrillation presented to the Neurology clinic for memory loss. It started with misplacing belongings, complicated by an episode of getting lost while driving to a familiar location. Examination showed 1/5 word recall at 5 minutes and mild impairment of serial sevens and abstract thinking. MRI brain revealed dilatation of the lateral and third ventricles out of proportion to the sulci and fourth ventricle, dolichoectatic basilar artery up to 8 mm with superior displacement of nearby structures and effacement of the anterior third ventricle. Repeat MRI with CSF flow one month later showed unchanged ventricular dilatation favored secondary to volume loss without evidence of an obstructive process. Conclusions These cases characterize the rare phenomenon of VBDE and highlights the importance of acquiring MRI with CSF flow when it presents with hydrocephalus