Neurology 2015

Treatment


1. Neurology. 2015 May 12;84(19):1927-32. doi: 10.1212/WNL.0000000000001562. Epub
2015 Apr 10.

CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in
nonacademic hospitals.

Blok KM(1), Rinkel GJ(1), Majoie CB(1), Hendrikse J(1), Braaksma M(1), Tijssen
CC(1), Wong YY(1), Hofmeijer J(1), Extercatte J(1), Kerklaan B(1), Schreuder
TH(1), ten Holter S(1), Verheul F(1), Harlaar L(1), Pruissen DM(1), Kwa VI(1),
Brouwers PJ(1), Remmers MJ(1), Schonewille WJ(1), Kruyt ND(1), Vergouwen MD(2).

Author information: 
(1)From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus
(K.M.B., G.J.E.R., M.D.I.V.), and Department of Radiology (J. Hendrikse),
University Medical Center Utrecht; Department of Radiology (C.B.L.M.M.), Academic
Medical Center, Amsterdam; Department of Neurology (M.B., C.C.T.), St. Elisabeth
Hospital, Tilburg; Department of Neurology (Y.Y.W., J. Hofmeijer), Rijnstate
Hospital, Arnhem; Department of Neurology (J.E., B.K.), Sint Lucas Andreas
Hospital, Amsterdam; Department of Neurology (T.H.C.M.L.S.), Atrium Medical
Center, Heerlen; Department of Neurology (S.t.H., F.V.), Groene Hart Hospital,
Gouda; Department of Neurology (L.H., D.M.O.P.), Diakonessenhuis, Utrecht;
Department of Neurology (V.I.H.K.), Onze Lieve Vrouwe Gasthuis, Amsterdam;
Department of Neurology (P.J.B.), Medisch Spectrum Twente, Enschede; Department
of Neurology (M.J.M.R.), Amphia Hospital, Breda; Department of Neurology
(W.J.S.), St. Antonius Hospital, Nieuwegein; and Department of Neurology
(N.D.K.), Slotervaart Hospital, Amsterdam, the Netherlands. N.D.K. is currently
affiliated with the Department of Neurology, Leiden University Medical Center,
the Netherlands. (2)From the Department of Neurology and Neurosurgery, Brain
Center Rudolf Magnus (K.M.B., G.J.E.R., M.D.I.V.), and Department of Radiology
(J. Hendrikse), University Medical Center Utrecht; Department of Radiology
(C.B.L.M.M.), Academic Medical Center, Amsterdam; Department of Neurology (M.B., 
C.C.T.), St. Elisabeth Hospital, Tilburg; Department of Neurology (Y.Y.W., J.
Hofmeijer), Rijnstate Hospital, Arnhem; Department of Neurology (J.E., B.K.),
Sint Lucas Andreas Hospital, Amsterdam; Department of Neurology (T.H.C.M.L.S.),
Atrium Medical Center, Heerlen; Department of Neurology (S.t.H., F.V.), Groene
Hart Hospital, Gouda; Department of Neurology (L.H., D.M.O.P.), Diakonessenhuis, 
Utrecht; Department of Neurology (V.I.H.K.), Onze Lieve Vrouwe Gasthuis,
Amsterdam; Department of Neurology (P.J.B.), Medisch Spectrum Twente, Enschede;
Department of Neurology (M.J.M.R.), Amphia Hospital, Breda; Department of
Neurology (W.J.S.), St. Antonius Hospital, Nieuwegein; and Department of
Neurology (N.D.K.), Slotervaart Hospital, Amsterdam, the Netherlands. N.D.K. is
currently affiliated with the Department of Neurology, Leiden University Medical
Center, the Netherlands. m.d.i.vergouwen@umcutrecht.nl.

OBJECTIVE: To investigate whether staff radiologists working in nonacademic
hospitals can adequately rule out subarachnoid hemorrhage (SAH) on head CT <6
hours after headache onset.
METHODS: In a multicenter, retrospective study, we studied a consecutive series
of patients presenting with acute headache to 11 nonacademic hospitals. Inclusion
criteria were (1) normal level of consciousness without focal deficits, (2) head
CT <6 hours after headache onset and reported negative for the presence of SAH by
a staff radiologist, and (3) subsequent CSF spectrophotometry. Two
neuroradiologists and one stroke neurologist from 2 academic tertiary care
centers independently reviewed admission CTs of patients with CSF results that
were considered positive for presence of bilirubin according to local criteria.
We investigated the negative predictive value for detection of SAH by staff
radiologists in nonacademic hospitals on head CT in patients scanned <6 hours
after onset of acute headache.
RESULTS: Of 760 included patients, CSF analysis was considered positive for
bilirubin in 52 patients (7%). Independent review of these patients' CTs
identified one patient (1/52; 2%) with a perimesencephalic nonaneurysmal SAH.
Negative predictive value for detection of subarachnoid blood by staff
radiologists working in a nonacademic hospital was 99.9% (95% confidence interval
99.3%-100.0%).
CONCLUSIONS: Our results support a change of practice wherein a lumbar puncture
can be withheld in patients with a head CT scan performed <6 hours after headache
onset and reported negative for the presence of SAH by a staff radiologist in the
described nonacademic setting.

© 2015 American Academy of Neurology.

PMID: 25862794  [PubMed - indexed for MEDLINE]


2. Neurology. 2015 Mar 10;84(10):e69-72. doi: 10.1212/WNL.0000000000001335.

Residency training: a failed lumbar puncture is more about obesity than lack of
ability.

Edwards C(1), Leira EC(1), Gonzalez-Alegre P(2).

Author information: 
(1)From the Department of Neurology, University of Iowa Carver College of
Medicine, Iowa City. (2)From the Department of Neurology, University of Iowa
Carver College of Medicine, Iowa City. pedro.gonzalez-alegre@uphs.upenn.edu.

OBJECTIVE: To identify factors influencing the success of lumbar puncture (LP)
performed by neurology residents in an outpatient clinic.
BACKGROUND: There is a need to understand the specific influence of patient or
operator characteristics in LP performance in order to identify situations at
high risk for failure that could benefit from compensatory interventions.
METHODS: We performed a retrospective analysis of all consecutive patients who
underwent elective LP in the Neurology Clinic at the University of Iowa between
2009 and 2012. We recorded demographic, anthropometric, and clinical information,
and the level of training of the resident performing the procedure. Outcomes
measure was unsuccessful LP, defined as no quantifiable CSF. This study was
previously approved by the University of Iowa institutional review board.
RESULTS: A total of 328 patients (59% women) were included. Men were
significantly older than women, and the indication of the procedure differed by
sex. Headache or possible multiple sclerosis were more common indications in
women than in men. Nineteen percent of the LPs were unsuccessful. We found a
strong correlation between patient body mass index (BMI) and unsuccessful outcome
(p < 0.0001). Age of the patient and level of training of the operator did not
predict unsuccessful LP.
CONCLUSIONS: Patient BMI is the key factor that determines an unsuccessful LP by
neurology residents in an outpatient setting, an association that might be
applicable to different clinical settings. The high failure rate in patients with
BMI >35 suggests that implementing compensatory interventions such as the use of
imaging guidance might be cost-effective and better tolerated by these patients.

© 2015 American Academy of Neurology.

PMID: 25754807  [PubMed - indexed for MEDLINE]


3. Neurology. 2015 Dec 1;85(22):1980-90. doi: 10.1212/WNL.0000000000002176. Epub
2015 Nov 4.

Endovascular vs medical management of acute ischemic stroke.

Chen CJ(1), Ding D(2), Starke RM(2), Mehndiratta P(2), Crowley RW(2), Liu KC(2), 
Southerland AM(2), Worrall BB(2).

Author information: 
(1)From the Departments of Neurological Surgery (C.-J.C., D.D., R.M.S., R.W.C.,
K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public Health Sciences (A.M.S.,
B.B.W.), University of Virginia Health System, Charlottesville.
chenjared@gmail.com. (2)From the Departments of Neurological Surgery (C.-J.C.,
D.D., R.M.S., R.W.C., K.C.L.), Neurology (P.M., A.M.S., B.B.W.), and Public
Health Sciences (A.M.S., B.B.W.), University of Virginia Health System,
Charlottesville.

OBJECTIVE: To compare the outcomes between endovascular and medical management of
acute ischemic stroke in recent randomized controlled trials (RCT).
METHODS: A systematic literature review was performed, and multicenter,
prospective RCTs published from January 1, 2013, to May 1, 2015, directly
comparing endovascular therapy to medical management for patients with acute
ischemic stroke were included. Meta-analyses of modified Rankin Scale (mRS) and
mortality at 90 days and symptomatic intracranial hemorrhage (sICH) for
endovascular therapy and medical management were performed.
RESULTS: Eight multicenter, prospective RCTs (Interventional Management of Stroke
[IMS] III, Local Versus Systemic Thrombolysis for Acute Ischemic Stroke
[SYNTHESIS] Expansion, Mechanical Retrieval and Recanalization of Stroke Clots
Using Embolectomy [MR RESCUE], Multicenter Randomized Clinical Trial of
Endovascular Treatment for Acute Ischemic Stroke in the Netherlands [MR CLEAN],
Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization
Effectiveness [ESCAPE], Extending the Time for Thrombolysis in Emergency
Neurological Deficits-Intra-Arterial [EXTEND-IA], Solitaire With the Intention
For Thrombectomy as Primary Endovascular Treatment [SWIFT PRIME], and
Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy
in Anterior Circulation Stroke Within 8 Hours [REVASCAT]) comprising 2,423
patients were included. Meta-analysis of pooled data demonstrated functional
independence (mRS 0-2) at 90 days in favor of endovascular therapy (odds ratio
[OR] = 1.71; p = 0.005). Subgroup analysis of the 6 trials with large vessel
occlusion (LVO) criteria also demonstrated functional independence at 90 days in
favor of endovascular therapy (OR = 2.23; p < 0.00001). Subgroup analysis of the
5 trials that primarily utilized stent retriever devices (≥70%) in the
intervention arm demonstrated functional independence at 90 days in favor of
endovascular therapy (OR = 2.39; p < 0.00001). No difference was found for
mortality at 90 days and sICH between endovascular therapy and medical management
in all analyses and subgroup analyses.
CONCLUSIONS: This meta-analysis provides strong evidence that endovascular
intervention combined with medical management, including IV tissue plasminogen
activator for eligible patients, improves the outcomes of appropriately selected
patients with acute ischemic stroke in the setting of LVO.

© 2015 American Academy of Neurology.

PMID: 26537058  [PubMed - in process]


4. Neurology. 2015 Aug 18;85(7):573-9. doi: 10.1212/WNL.0000000000001844. Epub 2015
Jul 17.

Effect of clopidogrel with aspirin on functional outcome in TIA or minor stroke: 
CHANCE substudy.

Wang X(1), Zhao X(1), Johnston SC(1), Xian Y(1), Hu B(1), Wang C(1), Wang D(1),
Liu L(1), Li H(1), Fang J(1), Meng X(1), Wang A(1), Wang Y(1), Wang Y(2); CHANCE
investigators.

Author information: 
(1)From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W.,
Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University,
Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.),
University of California, San Francisco; Duke Clinical Research Institute (DCRI) 
(Y.X.), Duke University, Durham, NC; the Department of Quantitative Health
Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare
System, University of Illinois College of Medicine, Peoria; and Institute for
Clinical Evaluative Sciences (J.F.), Toronto, Canada. (2)From the Department of
Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), 
Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the
Departments of Neurology and Epidemiology (S.C.J.), University of California, San
Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University,
Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland
Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of
Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative
Sciences (J.F.), Toronto, Canada. yilong528@gmail.com yongjunwang1962@gmail.com.

Comment in
    Neurology. 2015 Aug 18;85(7):562-3.

OBJECTIVE: We compared the effect of clopidogrel plus aspirin vs aspirin alone on
functional outcome and quality of life in the Clopidogrel in High-risk Patients
with Acute Non-disabling Cerebrovascular Events (CHANCE) trial of
aspirin-clopidogrel vs aspirin alone after acute minor stroke or TIA.
METHODS: Participants were assessed at 90 days for functional outcome using the
modified Rankin Scale (mRS) and quality of life using the EuroQol-5 Dimension
(EQ-5D). Poor functional outcome was defined as mRS score of 2-6 at 90 days and
poor quality of life as EQ-5D index score of 0.5 or less.
RESULTS: Poor functional outcome occurred in 254 patients (9.9%) in the
clopidogrel-aspirin group, as compared with 299 (11.6%) in the aspirin group (p =
0.046). Poor quality of life occurred in 142 (5.5%) in the clopidogrel-aspirin
group and in 175 (6.8%) in the aspirin group (p = 0.06). Disabling stroke at 90
days occurred in 166 (6.5%) in the clopidogrel-aspirin group and in 219 (8.5%) in
the aspirin group (p = 0.01). In stratified analysis by subsequent stroke, there
was no difference in 90-day functional outcome and quality of life between the 2
groups.
CONCLUSIONS: In patients with minor stroke or TIA, the combination of clopidogrel
and aspirin appears to be superior to aspirin alone in improving the 90-day
functional outcome, and this is consistent with a reduction in the rate of
disabling stroke in the dual antiplatelet arm.
CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for
patients with acute minor stroke or TIA, clopidogrel plus aspirin compared to
aspirin alone improves 90-day functional outcome (absolute reduction of poor
outcome 1.70%, 95% confidence interval 0.03%-3.42%).

© 2015 American Academy of Neurology.

PMCID: PMC4548281 [Available on 2016-08-18]
PMID: 26283758  [PubMed - indexed for MEDLINE]


5. Neurology. 2015 Apr 14;84(15):1552-8. doi: 10.1212/WNL.0000000000001473. Epub
2015 Mar 18.

Recurrence of reversible cerebral vasoconstriction syndrome: a long-term
follow-up study.

Chen SP(1), Fuh JL(1), Lirng JF(1), Wang YF(1), Wang SJ(2).

Author information: 
(1)From the Faculty of Medicine (S.-P.C., J.-L.F., J.-F.L., Y.-F.W., S.-J.W.),
National Yang-Ming University School of Medicine, Taipei; Department of
Neurology, Neurological Institute (S.-P.C., J.-L.F., Y.-F.W., S.-J.W.), and
Department of Radiology (J.-F.L.), Taipei Veterans General Hospital, Taipei;
Brain Research Center (S.-P.C., J.-L.F., Y.-F.W., S.-J.W.), Institute of Clinical
Medicine (Y.-F.W.), and Institute of Brain Science (S.-J.W.), National Yang-Ming
University, Taipei, Taiwan. (2)From the Faculty of Medicine (S.-P.C., J.-L.F.,
J.-F.L., Y.-F.W., S.-J.W.), National Yang-Ming University School of Medicine,
Taipei; Department of Neurology, Neurological Institute (S.-P.C., J.-L.F.,
Y.-F.W., S.-J.W.), and Department of Radiology (J.-F.L.), Taipei Veterans General
Hospital, Taipei; Brain Research Center (S.-P.C., J.-L.F., Y.-F.W., S.-J.W.),
Institute of Clinical Medicine (Y.-F.W.), and Institute of Brain Science
(S.-J.W.), National Yang-Ming University, Taipei, Taiwan. sjwang@vghtpe.gov.tw.

Comment in
    Neurology. 2015 Apr 14;84(15):1557.

OBJECTIVE: We aimed to investigate whether reversible cerebral vasoconstriction
syndrome (RCVS) could recur and to identify the potential predictors of
recurrence in a large cohort of patients.
METHODS: This study followed a cohort of 210 patients with RCVS in a
hospital-based headache center from 2000 to 2012. All patients were regularly
followed up by telephone after remission for RCVS and were particularly asked to
return to our hospital immediately if they developed new acute, severe (i.e.,
thunderclap-like) headaches. Sequential neuroimaging studies were used to
determine whether the patients had recurrent RCVS.
RESULTS: One hundred sixty-eight patients were successfully followed. The
response rate was 80.8%, and the mean follow-up period was 37.5 ± 24.4 (range
6-131) months. Eighteen patients (10.7%) returned to our hospital because of new
thunderclap-like headaches, and 9 (5.4% of the total 168, and 50% of 18) were
confirmed to have recurrent RCVS that occurred a mean 40.9 ± 27.2 (median 35,
range 6-87) months after the initial bout. The incidence rate was 1.71 per 100
person-years (95% confidence interval 1.68-1.75). Having sexual activities as a
trigger for thunderclap headaches (hazard ratio = 5.68, 95% confidence interval
1.11-29.15, p = 0.038) was an independent predictor of recurrent RCVS. None of
the patients with recurrent RCVS developed cerebrovascular complications.
CONCLUSIONS: Recurrent RCVS should be considered when patients with RCVS develop
new thunderclap-like headaches. Having sexual activities as a trigger for RCVS is
a potential predictor of recurrent RCVS.

© 2015 American Academy of Neurology.

PMID: 25788554  [PubMed - indexed for MEDLINE]

Diagnostic

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Review

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Clinical Prediction Rules

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