Primary glioblastoma of the spinal cord (sGB) is a rare and challenging diagnosis. In the diagnostic algorithm, reversible causes should be considered while the diagnosis of sGB is under evaluation. We present a case of cervical sGB mimicking neuroschistosomiasis. A 21-year-old Somali man presented with neck pain, sensory disturbances, and spastic tetraplegia. Cervical spine magnetic resonance imaging with contrast showed a heterogeneously enhancing intramedullary mass spanning from the level of the C1 to T3 vertebrae. Cerebrospinal fluid analysis showed a lymphocytic predominance and elevated protein. Due to the patient's history of poorly treated schistosomiasis, praziquantel and dexamethasone were initiated while the diagnostic work-up was completed. Three days after the patient was discharged to a rehabilitation facility where he experienced worsened motor function with radiographic progression of the lesion and increased cord edema. The patient underwent a surgical biopsy which confirmed a diagnosis of primary sGB. sGB is an unusual diagnosis that can masquerade as a non-neoplastic lesion. However, the diagnosis of sGB should be considered in patients with an intramedullary spinal cord lesion who exhibit rapid radiographic and clinical progression.
To the Editor: Sleep disordered breathing (SDB) is underdiagnosed in children and difficult to differentiate from attention deficit hyperactivity disorder (ADHD). Both may present with similar symptoms of inattention, hyperactivity, irritability, and daytime sleepiness. Sleep disordered breathing includes primary snoring or obstructive sleep apnea, which are surprisingly common among children with hyperactivity. Adenotonsillar hypertrophy is the primary cause of obstructive sleep apnea between the ages of 2 and 8 years, coinciding with the age onset of ADHD, thus creating a difficult differential diagnosis. Sleep in these cases may be adequate in duration, but fragmented with frequent arousals that result in daytime dysfunction. Intermittent hypoxia during apnea causes inflammatory vascular changes in the brain, resulting in neurocognitive dysfunction, while sleep fragmentation causes inattentiveness. Approximately 25% of children with signs of ADHD also have evidence for SDB; about 28% of those scheduled for adenotonsillectomy exhibit criteria for ADHD (vs 7% for surgical controls). At 1 year post-adenotonsillectomy, 50% of them no longer meet the criteria for ADHD. Among adenotonsillectomy subjects with ADHD symptoms, 78% no longer evidenced ADHD after 6 months. Significant snoring is reported to be 2 times more common in children with ADHD than in other pediatric populations. It is important to screen for SDB in children who present with hyperactivity and/or inattention. Children with ADHD-like symptoms should be screened for signs of sleep disorders, such as snoring, apneas, and/or awakenings accompanied by gasping. When SDB is suspected, assessment includes a history, physical examination, X-ray of the neck, and fiberoptic endoscopy to rule out adenotonsillar hypertrophy. Polysomnography is the definitive means to diagnose SDB. Since SDB is rarely suspected in hyperactive children, detailed screening and diagnostic evaluation are critical. Psychostimulant treatment of a child with SDB may result in more sleep disturbance and dysfunctional behavior.
Background: Decline in presentations of acute stroke during the early period of COVID-19 pandemic have been reported. We aimed to investigate the stroke presentations during the subsequent months as the pandemic evolved into a second wave. Methods: Data was obtained from a health system with 19 emergency departments (EDs) in northeast Ohio in the United States. Baseline period from January 1 to February 29, 2020, was compared with the individual months during COVID-19 period from March through July. Variables included were numbers of daily stroke alerts across the EDs, thrombolysis, thrombectomy, time to presentation, stroke severity, time from door-to-needle in thrombolysis, and door-to puncture in thrombectomy. The time periods were compared using nonparametric statistics and Poisson regression with month, weekend, and daily COVID cases as independent variables. Results: A total of 2264 stroke alerts from EDs were analyzed between January 1 to July 31, 2020. Total daily stroke alerts decreased from a median of 10 (interquartile range [IQR]:10-13) in January and February to 9 (IQR:6-11, p=0.001) in March, 8(IQR:7-10, p=0.0001) in April, 10 (IQR:8-11, p=0.04) in May, and returned similar to baseline in June (12, IQR:10-13, p=0.5) and July (13, IQR:11-14,p=0.1). In Poisson regression, stroke alert numbers showed no significant association with daily COVID-19 counts, but significant association with months, with rate ratios of 0.74 (95%CI 0.64-0.85) for March, 0.71 (95%CI 0.61-0.82) for April, and 0.86 (95%CI 0.75-0.98) for May, but not with June and July. Time to presentation and stroke severity were unchanged throughout the study period. Thrombolysis volume decreased in March and May but thrombectomy volume was unchanged. Conclusion: We observed a decrease in stroke presentations across emergency departments by about 30% during the early period of COVID-19 pandemic, followed by return to baseline frequency despite a second wave of COVID-19 cases.
Background: Noncontrast CT is the most widely utilized stroke imaging method. TESLA aimed to assess the efficacy and safety of intraarterial treatment for large infarct patients identified using noncontrast CT alone.Methods: TESLA was a multicentre, open-label, blinded-endpoint, randomised, controlled trial conducted at 47 U.S. hospitals. Ischaemic stroke patients aged 18-85 years, presenting within 24 hours with anterior-circulation large-vessel occlusion and large infarct on noncontrast CT (Alberta Stroke Program Early CT Score [ASPECTS] 2-5) were randomly assigned (1:1) to receive intraarterial treatment (intervention) or no intraarterial treatment (control). Web-based, permuted-block randomisation was stratified for age, ASPECTS, neurologic deficit, and stroke onset-to-imaging time. The primary outcome was 90-day mean utility-weighted modified Rankin scale (uw-mRS) score (intention-to-treat population). Safety outcomes included 90-day mortality and symptomatic intracranial haemorrhage (as-treated population). A Bayesian model adjusting for ASPECTS determined the posterior probability that intervention would be superior to control. Statistical significance was a one-sided posterior probability ≥0·975. This trial was registered with ClinicalTrials.gov, NCT03805308.Findings: Between July 16, 2019, and October 17, 2022, 300 patients were enrolled (152 intervention and 148 control; 140 [47%] females). Mean 90-day uw-mRS score was 2·93 ± 3·39 among intervention patients versus 2·27 ± 2·98 among control patients (adjusted difference, 0·63 [95%CI -0·09, 1·34]; one-sided posterior probability, 0·96). Ninety-day mRS score 0-3 was more frequent with intervention (30% [45/151] versus 20% [29/146]; risk ratio, 1·50 [95%CI 1·00, 2·26]). Ninety-day mortality (35·3% [53/150] with intervention and 33·3% [49/147] with control) and 24-hour symptomatic haemorrhage (4·0% [6/151] and 1·3% [2/149], respectively) were similar.Interpretation: Among patients with a large infarct on noncontrast CT, intraarterial treatment did not significantly improve functional outcome. The observed signal of benefit for intraarterial treatment should be confirmed in other trials of this imaging approach. There were no safety concerns.Trial Registration: This trial was registered with ClinicalTrials.gov, NCT03805308.Funding: The TESLA trial was funded through unrestricted grants from Medtronic, Cerenovus, Penumbra, Stryker, and Genentech.Declaration of Interest: AJY reports research funding from Medtronic, Cerenovus, Penumbra, Stryker, and Genentech for the current study; consulting fees from Penumbra, Vesalio, Cerenovus, Philips Neurovascular, HCA, and the National Institutes of Health; stock options from Nicolab; equity interest in Insera Therapeutics and Gravity Medical; and serves as co-principal investigator of the CLEAR study (Vesalio) and the OPTIMA registry (Balt), endovascular safety monitor of the MOST trial (NIH), and core imaging lab of the THUNDER (Penumbra) and RECCLAIM 2 (Zoll Circulation) trials. OOZ reports research funding from Medtronic, Cerenovus, Penumbra, Stryker, and Genentech for the current study, and from Microvention for other research; and consulting fees from Stryker, Cerenovus, Penumbra, and Medtronic. All other authors declare no competing interests.Ethical Approval: The study was approved by the ethics committees of all participating centres. All patients or their legally authorized representatives provided written informed consent prior to enrollment.
Pentazocine is a mixed agonist/antagonist opioid analgesic agent that can induce an atypical myopathy following intramuscular injections. This iatrogenic myopathy is rare, typified by fibrosis, and should be differentiated from other myopathies. We describe a case of pentazocine-induced myopathy that caused wasting of musculature in the gluteal region bilaterally and stiffness and woody induration in the legs of 42-year-old man. Though rare, clinicians should be alerted to this potential side effect and avoid repeated administration of intramuscular pentazocine.
Declines in stroke admission, IV thrombolysis (IVT), and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the effect of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), IVT, and mechanical thrombectomy over a 1-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020).
Methods
We conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, IVT treatments, and mechanical thrombectomy procedures. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases.
Results
There were 148,895 stroke admissions in the 1 year immediately before compared with 138,453 admissions during the 1-year pandemic, representing a 7% decline (95% CI [95% CI 7.1–6.9]; p < 0.0001). ICH volumes declined from 29,585 to 28,156 (4.8% [5.1–4.6]; p < 0.0001) and IVT volume from 24,584 to 23,077 (6.1% [6.4–5.8]; p < 0.0001). Larger declines were observed at high-volume compared with low-volume centers (all p < 0.0001). There was no significant change in mechanical thrombectomy volumes (0.7% [0.6–0.9]; p = 0.49). Stroke was diagnosed in 1.3% [1.31–1.38] of 406,792 COVID-19 hospitalizations. SARS-CoV-2 infection was present in 2.9% ([2.82–2.97], 5,656/195,539) of all stroke hospitalizations.
Discussion
There was a global decline and shift to lower-volume centers of stroke admission volumes, ICH volumes, and IVT volumes during the 1st year of the COVID-19 pandemic compared with the prior year. Mechanical thrombectomy volumes were preserved. These results suggest preservation in the stroke care of higher severity of disease through the first pandemic year.
Background and Purpose: We aimed to investigate the characteristics of acute stroke intervention therapies during coronavirus disease 2019 (COVID-19) pandemic. Methods: The data were obtained from a comprehensive stroke center in the central region of the state of Kentucky in the United States. Pre-COVID period, which is before the first confirmed case in Kentucky, from January 1 to March 5 , 2020, was compared with the COVID period from March 6 to May 9, 2020. The variables included were total number of stroke alerts, final diagnosis of stroke, stroke severity scale, thrombolysis including intravenous and intra-arterial tissue plasminogen activator administration and mechanical thrombectomy. The 2 time periods were compared using nonparametric statistics. Results: Total thrombectomies were increased from median, 3( Interquartile range, 1-7) during pre-COVID period to median of 7( Interquartile range, 2-17, p=0.01) during COVID period. Intravenous thrombolysis and adjunct therapy with intra-arterial thrombolysis did not differ between two time periods. Conclusions: We observed an increase in acute stroke intervention therapies during the surge of COVID-19 cases in Kentucky. This observation could be attributed to the increased association of COVID-19 and acute ischemic stroke.
During the coronavirus disease 2019 (COVID-19) pandemic, we instituted virtual inpatient stroke rounds and acute stroke evaluations via telemedicine in the emergency department. We sought to explore trainees' and experienced providers' views on stroke care and education.The implementation and the survey took place at a single academic comprehensive stroke center in northeast Ohio in the United States. "Virtual rounding" consisted of patient presentation and discussion in the morning in on-line virtual team format followed by in-person patient rounds in small groups. Acute stroke evaluations in the emergency department included direct in-person evaluation by neurology residents with supervision over telemedicine.The neurology residents, stroke fellows, stroke nurse practitioners, and stroke staff physicians were surveyed 2 months after implementation. Quantitative data was analyzed using descriptive statistical analysis, written responses in comment sections were analyzed using content analysis.Thirty-two of 42 (73%) surveys were completed. Nine (45%) residents and 5 (42%) experienced providers responded that virtual rounds did not compromise learning and education on stroke service. Fifteen (75%) residents and all experienced providers agreed that virtual rounds protected caregivers from exposure to the virus. While more than a third of residents (37%) did not feel comfortable utilizing telemedicine in ED, the majority of experienced providers (89%) were at ease with it. A total of 58% of residents and 67% of experienced providers felt that they were spending less time at the bedside, and 42% of residents and 58% of experienced providers felt less connected to patients during the pandemic.Majority of neurology residents' experience was not positive utilising telemedicine as compared to other staff providers. This is likely attributed to lack of prior exposure and unpreparedness. Incorporation of telemedicine curricula in medical school and residency training could prepare the next generation physicians to effectively use these technologies and meet the growing need for telehealth services for current and future pandemics.
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