Objectives: Stroke is a leading cause of mortality and disability worldwide, particularly acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Although endovascular intervention has proven effective, individual outcomes vary considerably. This study aimed to identify key prognostic factors and develop a predictive model for neurological recovery in patients with LVO-AIS following endovascular thrombectomy (EVT). Methods: A total of 191 LVO-AIS patients who underwent EVT at the Neurosurgery Department of Zhejiang University Shaoxing Hospital from January 2022 to June 2023 were included in the analysis. Prognostic factors collected included demographic information, premorbid characteristics, initial laboratory data, neurological evaluation, and others. The 90‑day modified Rankin Scale (mRS) score served as the primary clinical outcome. A multilevel prognostic (MLP) model and an associated nomogram were developed to identify significant predictors and visualize their individual contributions to the outcome. Results: The Zhejiang University Shaoxing Hospital (ZJUSXH) model was developed, incorporating 11 key predictors: the National Institutes of Health Stroke Scale (NIHSS) score, symptom onset‑to‑recanalization (OTR) time, fasting blood glucose (FBS), hemoglobin (HGB), serum albumin (ALB), symptomatic intracerebral hemorrhage (sICH), the Controlling Nutritional Status (CONUT) score, the prognostic nutritional index (PNI), swallowing function, and the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. The overall predictive accuracy of the model was 86.2%. Conclusion: The NIHSS score and OTR time emerged as the most critical prognostic factors. FBS, HGB, ALB, sICH, swallowing function, and TOAST classification were also significant predictors. In addition, the CONUT score and PNI showed a significant association with neurological outcomes. Both the developed ZJUSXH model and its corresponding nomogram demonstrated high predictive accuracy.
Objectives: Many patients fail to access emergency services in time for acute stroke treatment. Artificial intelligence (AI) may help optimize prehospital triage. This study describes the development, refinement, and clinical validation of an AI-based virtual assistant (VA) for early stroke detection and appropriate emergency referral. Methods: A prospective cohort study was conducted between August 2024 and July 2025 in a tertiary care center in Buenos Aires, Argentina. The VA was applied to adult inpatients with acute stroke in a neurovascular unit. Before this, the tool had been optimized using a literature review and simulations with 1151 de-identified medical records. Clinical, demographic, and performance variables were recorded. The main outcomes were syndromic diagnostic alignment, identification of the most probable diagnosis, appropriate emergency referral, and user satisfaction. Results: A total of 78 participants were included (median age: 73 y; 56.4% male). The mean time from symptom onset to VA use was 2 days. Final diagnoses were ischemic stroke (80.8%), transient ischemic attack (11.5%), subarachnoid hemorrhage (5.1%), and intracerebral hemorrhage (2.6%). Syndromic diagnosis matched the clinical standard in 89.7% of cases; top-1 match in 71.8%, and top-3 in 91%. Emergency referral was adequate in 93.6% of cases. The median use involved 10 questions and 4 minutes. Over 90% rated the experience 4 or 5 out of 5. Conclusions: In this controlled validation involving patients with confirmed cerebrovascular disease, the AI-based VA demonstrated high agreement with clinical syndromic classification, appropriate urgency recommendations, and high user acceptance. Further evaluation in broader prehospital populations is warranted.
INTRODUCTION:Brain abscesses developing within a nonoperated intracranial hematoma are even rarer. We report brain abscesses developing within 2 hematomas and complicating a methicillin-sensitive Staphylococcus aureus (MSSA) infectious endocarditis (IE). CASE:A previously healthy 26-year-old man without risk factors was diagnosed at hospital day (HD) 2 with a parietal hematoma (24 mm). Angiography did not reveal any aneurysm. He underwent a biological aortic valve replacement at HD4. Valve culture was positive for MSSA. Subsequently, a frontal hematoma appeared, an enlargement of both hematomas, extensive and finger-like edema, and ring enhancement. The puncture of the largest abscess showed red jelly-like material, and the culture was positive for MSSA. Thereafter, the lesions progressively disappeared. CONCLUSION:We emphasize the difficulty of the diagnosis of brain abscess developing within a hematoma, due to the possible absence of clinical changes. However, clinicians should be aware of possible MRI changes. A contrast-enhanced sequence is of paramount importance in the follow-up of brain hematomas in IE patients.
Introduction: POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, and Skin changes) syndrome is a rare paraneoplastic disorder driven by proinflammatory cytokines, particularly vascular endothelial growth factor (VEGF), which promotes multisystemic angiogenesis and inflammation. It is frequently misdiagnosed as Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) due to overlapping features. Case Report: A 63-year-old woman was referred for presumed CIDP unresponsive to IVIG and steroids. Her clinical course was notable for 100-pound weight loss, papilledema, skin changes, thrombocytosis, thromboembolisms, hemi-diaphragmatic paralysis, organomegaly/lymphadenopathy, and negative bone marrow and lymph node biopsies. POEMS was diagnosed based on repeat electrodiagnostic testing, elevated VEGF and prolactin, and nerve/muscle biopsies showing endomysial edema and angiogenesis. Notably, no monoclonal protein (M-protein) was identified. Treatment with lenalidomide and dexamethasone resulted in significant clinical improvement. Conclusion: Paraprotein-negative POEMS syndrome should be considered in refractory CIDP, especially in the presence of skin changes, endocrinopathy, papilledema, and thrombocytosis. VEGF levels and nerve/muscle biopsy findings are critical diagnostic tools in patients with high clinical suspicion who lack monoclonal gammopathy. Muscle biopsy may increase the diagnostic yield by revealing characteristic vascular proliferation, a feature previously described in nerve biopsies of patients with POEMS syndrome.
Objectives: Paroxysmal atrial fibrillation (AF) is often challenging to detect in the acute phase of ischemic stroke. This study aimed to assess the diagnostic value of readily available cardiac structural metrics in identifying cardioembolic stroke etiology. Methods: In a single-center cohort study, we enrolled patients who underwent transthoracic echocardiography within 7 days of stroke onset. We measured the left atrium diameter (LAD), right atrium diameter (RAD), left ventricular internal diameter, right ventricular internal diameter, interventricular septal thickness at end-diastole (IVSd), left ventricular posterior wall thickness, and assessed for mitral and aortic regurgitation. The predictive performance of these metrics for cardioembolic stroke was evaluated by calculating the area under the receiver operating characteristic curve (AUC). Results: Among the 1357 enrolled patients, 101 (7.4%) were diagnosed with cardioembolic stroke. After adjusting for potential confounders, LAD, RAD, and IVSd remained independently associated with cardioembolic stroke in both the full population and in patients without AF. LAD demonstrated the highest discriminative ability, with an AUC of 0.744 (95% CI: 0.682-0.806). The AUCs for RAD and IVSd were 0.583 (0.510-0.657) and 0.584 (0.516-0.652), respectively. Conclusions: LAD is a good predictor for identifying cardioembolic stroke, independent of AF status. Cardiac structural metrics, particularly LAD, may aid in etiologic subtyping during the acute phase of ischemic stroke.
Introduction: Kimura’s disease is a chronic inflammatory disorder, while cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited cerebral small vessel disease. Case Report: A 56-year-old Chinese male with a 6-year history of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy was admitted due to recurrent cerebral infarcts. He also had a concurrent diagnosis of Kimura’s disease accompanied by hypereosinophilia and elevated serum immunoglobulin E levels. Although the patient had been on oral antiplatelet therapy, no preventive treatment had been previously administered for the hypereosinophilia or high immunoglobulin E levels. We conducted follow-up to track disease progression and to review the management approach, including its strengths and shortcomings. Conclusion: This case represents a rarely reported instance of Kimura’s disease coexisting with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. It underscores the importance of differentiating stroke etiologies and illustrates the potential for complications when hypereosinophilic conditions are left untreated.
Introduction: Internuclear ophthalmoplegia (INO) is a horizontal gaze disorder caused by medial longitudinal fasciculus lesions. INO of abduction is an exceptionally rare variant characterized by abduction limitation with preserved convergence and contralateral adduction nystagmus, with unclear pathophysiology, and only a limited number of cases have been reported. Case Report: A 27-year-old man presented with headache, vomiting, seizures, and altered sensorium. Examination revealed bilateral disc edema and abduction restriction of the right eye, with contralateral adduction nystagmus, consistent with INO of abduction. Brain MRI showed no brainstem lesions, while MR venography demonstrated cerebral venous thrombosis of the superior sagittal, left transverse, and sigmoid sinuses. Vitamin B12 deficiency with hyperhomocysteinemia was detected. Treatment with anticoagulation and acetazolamide resulted in complete resolution of the ocular motility deficits. Conclusion: This case highlights a reversible form of INO of abduction associated with raised intracranial pressure in the absence of structural brainstem lesions, likely due to pressure-mediated disruption of inhibitory gaze pathways. INO of abduction is an ultrarare but clinically important sign. Its recognition in patients with intracranial hypertension and normal brainstem imaging may aid in localization and facilitate timely, reversible treatment.
Objectives: Case reports indicate that caseous mitral annulus calcification (MAC), also termed mitral annulus caseous granuloma, may contribute to stroke and systemic embolism. This retrospective case-control study aimed to assess the prevalence of caseous MAC detected through cardiac computed tomography (CT) in an acute stroke cohort and to identify factors associated with its occurrence. Methods: A total of 149 patients with acute ischemic stroke who underwent emergency cardiac CT, 300 acute ischemic stroke patients who did not undergo cardiac CT, and 268 individuals who underwent cardiac CT but had no history of stroke were included. The first group was consecutively selected (January 2022 to November 2024), while the other 2 groups were identified through propensity matching based on age and sex. Various regression models were applied to determine the degree of association. Results: Caseous MAC was detected in 5.4% of stroke patients who underwent cardiac CT, a prevalence significantly higher than in the control group (1.1%, P =0.02). Regression models demonstrated that caseous MAC significantly ( P =0.011) and independently increased stroke risk by a factor of 7.57 to 10.81 (95% CI: 1.54-36.20). Conclusions: These findings suggest that caseous mitral annulus calcific granuloma may be a potential cause of embolic stroke. Further prospective, multicenter studies are needed to validate these results.
Objectives: Few studies have evaluated the applicability of a point-of-care ultrasound (POCUS) training program in neurocritical care. In this study, we aimed to investigate the clinical utility of expert-endorsed topics of the integrated POCUS program from a trainee’s perspective. Methods: Between 2022 and 2024, we held an annual “1-day POCUS hands-on training program.” The program was comprised of a “3-hour lecture” followed by a “5-hour hands-on workshop” on the following topics: carotid duplex examination, transcranial color-coded Doppler techniques, ultrasound examination for posterior circulation, chest ultrasonography, and echocardiography. Sixty trainees were recruited each year and were separated into 10 groups during hands-on workshop rotation. The trainees were asked to complete an anonymous survey after the workshop to evaluate their opinions, which was rated using a 5-point Likert scale and open questions. In addition, the trainees were required to complete multiple-choice tests both before and after the lecture. Results: A total of 179 trainees (85 attending physicians and 94 resident doctors) were recruited. The median clinical utility rating scores were 5 for all topics, and the mean score was highest for the carotid duplex lecture (4.91±0.29) and lowest for the echo-guided lumbar puncture lecture (4.38±0.97). In addition, the mean posttest score was significantly higher than the pretest score (9.65±1.86 vs. 7.69±1.70, P <0.001). Conclusions: Our study suggested the POCUS topics suitable for neurocritical care should integrate medical care and cerebral vascular evaluations, including anterior and posterior circulation. Our results may help to guide training courses and assessment tool design in the future.
OBJECTIVES:Many patients fail to access emergency services in time for acute stroke treatment. Artificial intelligence (AI) may help optimize prehospital triage. This study describes the development, refinement, and clinical validation of an AI-based virtual assistant (VA) for early stroke detection and appropriate emergency referral. METHODS:A prospective cohort study was conducted between August 2024 and July 2025 in a tertiary care center in Buenos Aires, Argentina. The VA was applied to adult inpatients with acute stroke in a neurovascular unit. Before this, the tool had been optimized using a literature review and simulations with 1151 de-identified medical records. Clinical, demographic, and performance variables were recorded. The main outcomes were syndromic diagnostic alignment, identification of the most probable diagnosis, appropriate emergency referral, and user satisfaction. RESULTS:A total of 78 participants were included (median age: 73 y; 56.4% male). The mean time from symptom onset to VA use was 2 days. Final diagnoses were ischemic stroke (80.8%), transient ischemic attack (11.5%), subarachnoid hemorrhage (5.1%), and intracerebral hemorrhage (2.6%). Syndromic diagnosis matched the clinical standard in 89.7% of cases; top-1 match in 71.8%, and top-3 in 91%. Emergency referral was adequate in 93.6% of cases. The median use involved 10 questions and 4 minutes. Over 90% rated the experience 4 or 5 out of 5. CONCLUSIONS:In this controlled validation involving patients with confirmed cerebrovascular disease, the AI-based VA demonstrated high agreement with clinical syndromic classification, appropriate urgency recommendations, and high user acceptance. Further evaluation in broader prehospital populations is warranted.
Various artificial intelligence-based medical technologies have been used for diagnosing and treating diseases. Although moyamoya disease (MMD) poses a significant threat to the lives of patients, artificial intelligence (AI) use in MMD is still limited. This study aims to review the literature on predicting, diagnosing, and treating MMD with AI, as well as to discuss its current status, challenges, and future directions. Using AI in treating MMD can enhance diagnostic accuracy and treatment outcomes. AI-driven imaging analysis aids in the early detection of vascular abnormalities linked to MMD, facilitating timely intervention and management. In addition, machine learning (ML) algorithms can analyze large data sets from clinical trials and patient records to identify patterns and predict outcomes, informing personalized treatment plans. AI has shown great potential in the diagnosis and treatment of MMD. The application of AI in treating MMD represents a promising frontier that may revolutionize clinical practices.
Cervical artery dissection (CeAD) is an important cause of ischemic stroke in young adults. Nearly 100 million annual chiropractic cervical manipulations are performed in the United States. The relationship between manipulation and CeAD remains controversial. We analyzed patients in the multicenter STOP-CAD registry (n=4023) to identify CeAD cases diagnosed after chiropractic cervical manipulation. Demographics and clinical features were compared between manipulation-associated and nonmanipulation-associated cases using χ 2 and t tests. Multivariable logistic regression identified key factors associated with manipulation-related CeAD. About 1 in 20 CeAD cases in this registry reported antecedent cervical manipulation. In multivariable binary logistic regression, compared with patients without prior manipulation, those with prior manipulation were younger (OR per year 0.98, 95% CI: 0.97-0.99, P =0.014), more often female (OR: 1.64, 95% CI: 1.21-2.23, P =0.001), less often diabetic (OR: 0.24, 95% CI: 0.08-0.78, P =0.018), presented with neck pain (OR: 2.80, 95% CI: 2.08-3.77, P <0.001), and had higher odds of isolated vertebral artery dissection (OR: 2.15, 95% CI: 1.57-2.94, P <0.001). Recurrent ischemic stroke rates were similar between groups. Given the very high number of manipulations performed annually, the absolute risk of secondary CeAD is extremely low. Manipulation-associated cases have distinct clinical features, occurring more often in younger women with vertebral dissections. Whether manipulation acts as a precipitating trigger or patients with early CeAD symptoms seek manipulation remains unresolved.
This study aims to identify retinal biomarkers of NOTCH3 mutation carriers using optical coherence tomography (OCT) data from the UK Biobank. We conducted a cross-sectional, matched case-control study of individuals with or without NOTCH3 mutation from the UK Biobank between 2006 and 2010. All participants had macular OCT scan and cognitive assessment. Cases were identified based on pathogenic/likely pathogenic NOTCH3 mutations and 1:1 matched with controls based on age, sex, hypertension, diabetes mellitus, and cigarette smoking status. Baseline characteristics and cognitive test scores were compared using χ 2 or Mann-Whitney U test appropriately. Macular thickness at central, inner, and outer subfields and at each retinal layer was compared using Wilcoxon signed-rank test. Our analysis included 134 participants (67 cases, 67 controls) with a mean age of 54 ± 9 years. NOCTH3 mutation carriers performed worse in prospective memory ( P =0.043), verbal and numerical reasoning ( P =0.178), visual memory ( P =0.227), and processing speed ( P =0.101) than matched controls. There were no differences in visual acuity between the 2 groups. NOTCH3 mutation carriers had significantly thinner macular inner subfield at the superior ( P =0.006), temporal ( P =0.008), and nasal ( P =0.034) quadrants, and significantly thinner macular RNFL ( P =0.008) compared with age-, sex-, and vascular risk factor-matched controls. The presence of NOTCH3 mutation is associated with reduced thickness in the inner macular subfield and macular RFNL. These retinal changes may reflect early pericyte dysfunction and microvascular ischemia. Longitudinal studies are needed to assess the temporal relationship between these retinal changes, cerebrovascular disease progression, and clinical severity of disease.
INTRODUCTION:Internuclear ophthalmoplegia (INO) is a horizontal gaze disorder caused by medial longitudinal fasciculus lesions. INO of abduction is an exceptionally rare variant characterized by abduction limitation with preserved convergence and contralateral adduction nystagmus, with unclear pathophysiology, and only a limited number of cases have been reported. CASE REPORT:A 27-year-old man presented with headache, vomiting, seizures, and altered sensorium. Examination revealed bilateral disc edema and abduction restriction of the right eye, with contralateral adduction nystagmus, consistent with INO of abduction. Brain MRI showed no brainstem lesions, while MR venography demonstrated cerebral venous thrombosis of the superior sagittal, left transverse, and sigmoid sinuses. Vitamin B12 deficiency with hyperhomocysteinemia was detected. Treatment with anticoagulation and acetazolamide resulted in complete resolution of the ocular motility deficits. CONCLUSION:This case highlights a reversible form of INO of abduction associated with raised intracranial pressure in the absence of structural brainstem lesions, likely due to pressure-mediated disruption of inhibitory gaze pathways. INO of abduction is an ultrarare but clinically important sign. Its recognition in patients with intracranial hypertension and normal brainstem imaging may aid in localization and facilitate timely, reversible treatment.
INTRODUCTION:Fibrocartilaginous embolism is a rare cause of spinal cord infarction. It can affect young healthy adults during physical exertion or the Valsalva maneuver. There is little evidence behind a fibrocartilaginous embolism causing spinal cord infarctions. The efficacy of thrombolytic therapy in spinal cord infarction is not well established. CASE REPORT:A 56-year-old male with hypertension presented with acute onset left arm and leg weakness after a Valsalva maneuver. The exam was remarkable for dense flaccid paralysis of the left arm and leg. Patient received thrombolytic therapy for suspicion of stroke. MRI C-spine revealed a nonenhancing lesion from C2 to C5 with diffusion restriction on DWI, suggesting a spinal infarct. He received 5 days of high-dose steroids with mild improvement of left lower extremity weakness. Labs were unremarkable for underlying inflammatory or demyelinating causes of myelopathy. We ruled out aortic dissection and cardioembolic causes. Upon further evaluation, the patient endorsed lifting heavy weights and had cervical spondylosis on imaging, which led to the diagnosis of fibrocartilaginous embolism. On 1-year follow-up, he is walking without support with some motor improvement in the distal left upper extremity. CONCLUSIONS:It is important to have a wide differential diagnosis in acute cases of myelopathy. In our patient's case, his diagnosis was one of exclusion. This case highlights a rare cause of spinal cord infarction in a middle-aged man. The efficacy of thrombolytic therapy in such cases needs further investigation.
INTRODUCTION:Oromandibular dyskinesia (OMD) is a rare movement disorder characterized by involuntary, repetitive, and often uncontrolled movements of the jaw, lips, and tongue. It may be associated with antipsychotics, antidepressants, anticonvulsants, and antibiotics. The OMD caused by antibiotics is very rare and often overlooked. CASE REPORT:We report here an 89-year-old female patient who had chewing-like oromandibular dyskinesia, defined by vertical jaw opening and closing motions, on the third day of oral levofloxacin medication, which began for community-acquired pneumonia. After cessation of levofloxacin and initiation of low-dose diazepam (5 mg/d), dramatic clinical improvement was observed within 48 hours, with symptoms nearly fully resolved by day 7. CONCLUSIONS:Fluoroquinolones can rarely cause movement disorders like OMD. The exact mechanism is unknown, but it may involve GABA imbalance. Stopping the drug and starting benzodiazepines may lead to a fast recovery.
INTRODUCTION:Longitudinally extensive transverse myelitis (LETM) is classically associated with aquaporin-4 antibody-mediated neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). The "H-sign," reflecting gray matter involvement, is considered suggestive of MOGAD. However, infectious etiologies, including neurosyphilis, may rarely mimic autoimmune inflammatory myelopathies radiologically. CASE REPORT:A 50-year-old man presented with 6 months of erectile dysfunction and urinary retention, followed by progressive gait instability. Examination revealed spastic paraparesis with tetrapyramidal signs, saddle hypoesthesia, and impaired vibration sense. Thoracic spine MRI demonstrated LETM from T4 to T10 with central gray matter involvement forming the "H-sign." Postcontrast sequences showed intense pial and intramedullary enhancement with inversion of signal intensity ("flip-flop sign"), suggestive of inflammatory meningomyelitis. Brain MRI was normal. Serum treponemal tests were reactive, and cerebrospinal fluid analysis revealed lymphocytic pleocytosis, elevated protein, and positive VDRL, confirming neurosyphilis. MOG-IgG and AQP4-IgG were negative using validated cell-based assays. The patient received intravenous benzylpenicillin combined with high-dose corticosteroids, resulting in significant clinical improvement and partial radiologic resolution at 6 months. CONCLUSION:Neurosyphilis is a rare but treatable cause of LETM and may radiologically mimic antibody-mediated demyelinating disorders, including MOGAD. The coexistence of the "H-sign" and the flip-flop enhancement pattern highlights the diagnostic overlap between infectious and autoimmune myelitis. Careful exclusion of infectious etiologies remains essential in patients presenting with LETM to ensure appropriate therapy and avoid unnecessary immunosuppression.
