BACKGROUND:Patients presenting with cervical artery dissection (CAD) are at risk for subsequent ischemic events. We aimed to identify characteristics that are associated with increased risk of ischemic stroke after initial presentation of CAD and to evaluate the differential impact of anticoagulant versus antiplatelet therapy in these high-risk individuals. METHODS:This was a preplanned secondary analysis of the STOP-CAD study (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection), a multicenter international retrospective observational study (63 sites from 16 countries in North America, South America, Europe, Asia, and Africa) that included patients with CAD predominantly between January 2015 and June 2022. The primary outcome was subsequent ischemic stroke by day 180 after diagnosis. Clinical and imaging variables were compared between those with versus without subsequent ischemic stroke. Significant factors associated with subsequent stroke risk were identified using stepwise Cox regression. Associations between subsequent ischemic stroke risk and antithrombotic therapy type (anticoagulation versus antiplatelets) among patients with identified risk factors were explored using adjusted Cox regression. RESULTS:In all, 4023 patients (mean age was 47.4 years; 44.5% were women) were included. By day 180, subsequent ischemic stroke occurred in 5.3% of the cohort. In adjusted Cox regression, factors associated with increased risk of subsequent ischemic stroke were prior history of ischemic stroke (adjusted hazard ratio [aHR], 7.31 [95% CI, 1.61-33.13]; P=0.010), presentation within 7 days from first symptoms (aHR, 3.04 [95% CI, 1.04-8.91]; P=0.043), infarct on baseline imaging (aHR, 9.85 [95% CI, 3.65-26.58]; P<0.001), and occlusive dissection (aHR, 2.34 [95% CI, 1.03-5.34]; P=0.043). Only patients with occlusive dissection demonstrated a reduced risk of subsequent ischemic stroke when treated with anticoagulation versus antiplatelets (aHR, 0.36 [95% CI, 0.16-0.80]; P=0.01). CONCLUSIONS:In this post hoc analysis of the STOP-CAD study, several factors associated with subsequent ischemic stroke were identified among patients with CAD. Furthermore, we identified a potential benefit of anticoagulation in patients with CAD with occlusive dissection. These findings require validation by meta-analyses of prior studies to formulate optimal treatment strategies for specific high-risk CAD subgroups.

Abstract Background Intracranial atherosclerotic disease (ICAD) represents a leading cause of ischemic stroke worldwide, conferring increased risk of recurrent stroke and poor clinical outcomes among stroke survivors. Emerging evidence indicates a paradigm shift, pointing towards increasing detection rates of ICAD among White populations and an evolving epidemiological profile across racial and ethnic groups. The present review aims to provide a comprehensive overview of ICAD, focusing on its pathophysiology, diagnostic approach, and evolving epidemiological trends, including underlying mechanisms, advanced neuroimaging techniques for diagnostic evaluation, racial disparities in prevalence, and current and emerging management strategies. Main body Atherosclerotic plaque accumulation and progressive arterial stenosis of major intracranial arteries comprise the pathophysiological hallmark of ICAD. In clinical practice, the diagnosis of intracranial artery stenosis (ICAS) or high-grade ICAS is reached when luminal narrowing exceeds 50% and 70%, respectively. Advanced neuroimaging, including high-resolution vessel wall MRI (HRVW-MRI), has recently enabled ICAD detection before luminal stenosis occurs. While earlier studies disclosed significant racial disparities in ICAS prevalence, with higher rates among Asians, Hispanics, and Blacks, recent evidence reveals rising detection rates of ICAD among White populations. Genetic, environmental and epigenetic factors have been suggested to confer an increased susceptibility of certain ethnicities and races to ICAD. Nevertheless, with improved accessibility to advanced neuroimaging, ICAD is increasingly recognized as an underlying stroke etiology among White patients presenting with acute ischemic stroke and stroke of undetermined etiology. While conventional management of ICAS entails risk factor modification, pharmacotherapy, and endovascular treatment in selected high-risk patients, substantial progress remains to be made in the management of ICAD at its early, pre-stenotic stages. Conclusion ICAD remains a critical yet underappreciated risk factor for ischemic stroke across all populations, highlighting the need for increased awareness and improved diagnostic strategies. The emerging epidemiological profile of ICAD across racial groups necessitates a reassessment of risk factors, screening protocols and preventive strategies. Future research should focus on refining the diagnostic criteria and expanding the therapeutic options to cover the full spectrum of ICAD, with the aim of improving patient outcomes and reducing the global burden of intracranial atherosclerosis and stroke.

Aim: The Stroke Units Necessity for Patients (SUN4P) project aims to provide essential data on stroke healthcare in Greece. Herein, we present results on established quality indicators and outcomes after first-ever stroke occurrences. Methods: This prospective multicenter study included consecutive patients admitted to nine hospitals across Greece in 2019–2021. Descriptive statistics were used to present patients’ characteristics, key performance measures and stroke outcomes. Results: Among 892 patients, 755 had ischemic stroke (IS) (mean age 75.6 ± 13.6, 48.7% males) and 137 had hemorrhagic stroke (HS) (mean age 75.8 ± 13.2, 57.7% males). Of those, 15.4% of IS and 8% of HS patients were treated in the acute stroke unit (ASU) and 20.7% and 33.8% were admitted to the intensive care unit (ICU) or high-dependency unit (HDU), respectively. A total of 35 (4.6%) out of 125 eligible patients received intravenous alteplase with a door-to needle time of 60 min (21–90). The time to first scan for IS patients was 60 min (31–105) with 53.2% undergoing a CT scan within 60 min post presentation. Furthermore, 94.4% were discharged on antiplatelets, 69.8% on lipid-lowering therapy and 61.6% on antihypertensives. Oral anticoagulants (OAC) were initiated in 73.2% of the 153 IS patients with atrial fibrillation (AF). Among the 687 IS patients who survived, 85.4% were discharged home, 12% were transferred to rehabilitation centers, 1.2% to nursing homes and 1.3% to another hospital. Conclusions: The SUN4P Registry is the first study to provide data from a prospectively collected cohort of consecutive patients from nine representative national hospitals. It represents an important step in the evaluation and improvement of the quality of acute stroke care in Greece.

Objective: Patients with cervical artery dissection (CAD) are at increased ischemic stroke risk. We aimed to identify characteristics that are associated with increased risk of ischemic stroke following initial presentation of CAD and to evaluate the differential impact of anticoagulant versus antiplatelet therapy in these high-risk individuals. Methods: This was a secondary analysis of the Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection (STOP-CAD) study, a multicenter retrospective observational study. The primary outcome was subsequent ischemic stroke by day 180 after diagnosis. Patient characteristics were compared between those with vs. without subsequent ischemic stroke. Significant predictors were identified using stepwise Cox regression. Associations between subsequent ischemic stroke risk and antithrombotic therapy type in high-risk patients were explored using adjusted Cox regression. Results: 4,023 patients (mean age 47.4 years; 44.5% were women) were included. By day 180, 5.3% experienced a subsequent ischemic stroke. In adjusted Cox regression, factors associated with increased subsequent ischemic stroke risk were prior ischemic stroke (aHR 7.31, 95% CI 1.61-33.13, p=0.010), presentation within seven days from symptoms, (aHR 3.04, 95% CI 1.04-8.91, p=0.043), infarct on imaging (aHR 9.85, 95% CI 3.65-26.58, p<0.001), and occlusive dissection (aHR 2.34, 95% CI 1.03-5.34, p=0.043). Only patients with occlusive dissection had reduced subsequent ischemic stroke risk with anticoagulation versus antiplatelets (HR 0.37; 95% CI 0.15-0.89, p=0.03). Interpretation: This study identified several predictors of subsequent ischemic stroke among patients with CAD but only patients with occlusive dissection demonstrated a benefit from anticoagulation. These findings require validation by meta-analyses of prior studies. ### Competing Interest Statement CHN received funding from German Center for cardiovascular Research (DZHK) and German Center for neurodegenerative diseases (DZNE). CHN reports honoraria for lectures and/or speakers bureau from Abbott, Alexion, Astra Zeneca, BMS, Daiichi Sankyo, Novartis, Pfizer, Portola and Takeda. TNN reports advisory board for Brainomix, Aruna Bio; Associate Editor of Stroke. ### Funding Statement This study was not funded. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This analysis was conducted in accordance with the ethical guidelines of the original STOP-CAD study, which received Institutional Review Board (IRB) approval. As this is a secondary analysis of de-identified data, additional IRB approval was waived by the Lifespan IRB. Aggregate data will be shared upon reasonable request to the STOP-CAD principal investigator. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes This analysis was conducted in accordance with the ethical guidelines of the original STOP-CAD study, which received Institutional Review Board (IRB) approval. As this is a secondary analysis of de-identified data, additional IRB approval was waived by the Lifespan IRB. Aggregate data will be shared upon reasonable request to the STOP-CAD principal investigator.

Cluster headache (CH), a highly disabling condition, lacks disease-specific, mechanism-based prophylactic treatment. Galganezumab, a monoclonal antibody targeting the calcitonin gene-related peptide, reduced the weekly attacks of CH in one randomized, placebo-controlled trial for the prevention of episodic CH (eCH), but this effect was not detected in people with chronic CH (cCH). In this case series, we systematically monitored the efficacy and safety outcomes of adjunctive therapy in 11 people with refractory CH (failure of ≥ 3 prophylactic treatments; eCH n = 5, cCH, n = 6) who received galcanezumab (120-360 mg monthly) for 3 consecutive months. All participants received intermediate treatment with oral steroids or a great occipital nerve block ≥ 2 months before starting galcanezumab treatment. After galcanezumab treatment, the average number of weekly CH attacks and weekly days with any symptomatic treatment for CH decreased significantly from 16.0 ± 9.4 and 6.50 ± 3.59 before treatment to 1.8 ± 1.32 (p = 0.002) and 1.8 ± 3.36 (p = 0.001) at month 3 of treatment, respectively. Two participants with cCH showed no change in the number of attacks with galcanezumab. No serious adverse events were recorded. These data, along with those of previous real-world reports, suggest that galcanezumab may help people with refractory CH as an add-on treatment.

Background: Cluster headache (CH), currently one of the most painful conditions, lacks a well-established, disease specific, and mechanism-based prophylactic treatment. Galganezumab, a monoclonal antibody targeting the calcitonin gene-related peptide, reduced the weekly attacks of CH in one randomized, placebo-controlled trial for the prevention of episodic CH (eCH), but this effect was not detected in people with chronic CH (cCH). Objective: To explore the efficacy and safety of galcanezumab for the prevention of CH in people with refractory CH in a real-world setting. Methods: In this observational study, we systematically monitored the efficacy and safety outcomes of adjunctive therapy in patients with refractory CH (failure of ≥3 prophylactic treatments) who received galcanezumab (120–360 mg monthly) for 3 consecutive months. A detailed headache diary with monthly in-person follow-ups was used. All participants received intermediate treatment with oral steroids or a great occipital nerve block ≥2 months before starting galcanezumab treatment. Results: Data from 11 people with CH (eCH n=5, cCH, n=6) were collected. After galcanezumab treatment, the average number of weekly CH attacks and weekly days with any symptomatic treatment for CH decreased significantly from 16.0±9.4 and 6.50±3.59 before treatment to 1.8±1.32 (p=0.002) and 1.8±3.36 (p=0.001) at month 3 of treatment, respectively.Two participants with cCH showed no change in the number of attacks with galcanezumab. No serious adverse events were recorded. Conclusion: These data, along with those of previous real-world reports, suggest that galcanezumab may help people with refractory CH as an add-on treatment.

Background: Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy, which was first identified in 2016, is an immune-mediated inflammatory disorder of the nervous system characterized by antibodies targeting GFAP. The exact pathogenic mechanisms, as well as the role of anti-GFAP antibodies, remain unclear; however, it seems that neuroinflammation is mediated by specific CD8+ T-cells and that neoplasms or viral infections can act as the initial trigger. Although the clinical spectrum of the disease is broad and heterogenous, GFAP astrocytopathy most commonly presents as meningoencephalitis with or without myelitis. Other symptoms include headache, visual disturbances, extrapyramidal or brainstem syndromes, and psychiatric manifestations including psychosis. The disease has a characteristically favorable response to steroid treatment while relapses occur in approximately 20–30% of the patients. Methods: We present two cases of GFAP astrocytopathy admitted to our hospital: a 43-year-old male with persistent headache and a 59-year-old female with acute dysarthria and swallowing difficulties followed by cognitive and behavioral symptoms. Results: Additionally, we conduct a comprehensive review of the literature to elucidate the role of anti-GFAP antibodies in disease pathogenesis and examine imaging characteristics, clinical manifestations, and treatment options for this recently described neuroimmunological condition. Conclusions: This review presents two unusual cases of GFAP-astrocytopathy and provides evidence for the pathogenesis, clinical presentation, imaging characteristics and treatment options of the disease.

Introduction: Data on the association between blood pressure variability (BPV) after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) and outcomes are limited. We sought to identify whether BPV within the first 24 hours post EVT was associated with key stroke outcomes.Methods: We combined individual patient-data from five studies among AIS-patients who underwent EVT, that provided individual BP measurements after the end of the procedure. BPV was estimated as either systolic-BP (SBP) standard deviation (SD) or coefficient of variation (CV) over 24 h post-EVT. We used a logistic mixed-effects model to estimate the association [expressed as adjusted odds ratios (aOR)] between tertiles of BPV and outcomes of 90-day mortality, 90-day death or disability [modified Rankin Scale-score (mRS) > 2], 90-day functional impairment (>= 1-point increase across all mRS-scores), and symptomatic intracranial hemorrhage (sICH), adjusting for age, sex, stroke severity, co-morbidities, pretreatment with intravenous thrombolysis, successful recanalization, and mean SBP and diastolic-BP levels within the first 24 hours post EVT.Results: There were 2640 AIS-patients included in the analysis. The highest tertile of SBP-SD was associated with higher 90-day mortality (aOR:1.44;95% CI:1.08-1.92), 90-day death or disability (aOR:1.49;95% CI:1.18-1.89), and 90-day functional impairment (adjusted common OR:1.42;95% CI:1.18-1.72), but not with sICH (aOR:1.22;95% CI:0.76-1.98). Similarly, the highest tertile of SBP-CV was associated with higher 90-day mortality (aOR:1.33;95% CI:1.01-1.74), 90-day death or disability (aOR:1.50;95% CI:1.19-1.89), and 90-day functional impairment (adjusted common OR:1.38;95% CI:1.15-1.65), but not with sICH (aOR:1.33;95% CI:0.83-2.14).Conclusions: BPV after EVT appears to be associated with higher mortality and disability, independently of mean BP levels within the first 24 h post EVT. BPV in the first 24 h may be a novel target to improve outcomes after EVT for AIS.

BACKGROUND:Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with cervical artery dissection treated with antiplatelets versus anticoagulation. METHODS:This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-treated crossover approach and only included outcomes occurring with the above treatments. RESULTS:The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12]; P=0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24]; P=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45]; P=0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13]; P=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88]; Pinteraction=0.009). CONCLUSIONS:Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.

Background and purposeCervical artery dissection (CAD) represents a leading cause of unilateral lower cranial nerve IX-XII palsy, known as Collet-Sicard syndrome (CSS). High-resolution magnetic resonance imaging (HR-MRI) is widely used in the evaluation of patients with CAD, providing information regarding vessel wall abnormalities and intraluminal thrombus. MethodsWe present a patient with palsy of multiple lower cranial nerves in the context of CSS, attributed to unilateral spontaneous internal carotid artery dissection. ResultsWe describe a 68-year-old man with unremarkable previous history, who presented with subacute, gradually worsening dysphagia and hoarse voice. Clinical examination revealed right-sided palsy of cranial nerves IX-XII. Three-dimensional fat-saturated black-blood T1-weighted high-resolution vessel wall imaging disclosed spontaneous dissection with intramural hematoma along the distal right internal carotid artery. Neck MRI showed inward displacement of right aryepiglottic fold, right pyriform sinus dilatation, and right true vocal cord in middle position, indicative of right vagus nerve palsy, atrophy of right trapezius and sternocleidomastoid muscles, due to right spinal accessory nerve palsy, and unilateral tongue atrophy with fatty infiltration, characteristic for right hypoglossal nerve palsy. ConclusionsThis case highlights the utility of high-resolution vessel wall imaging and especially fat-saturated T1-weighted black-blood SPACE (sampling perfection with application-optimized contrast using different flip-angle evolutions) sequences in the accurate diagnosis of CAD, revealing the characteristic mural hematoma and intimal flap. HR-MRI is also valuable in the recognition of indirect signs of lower cranial nerve compression.

A 28-year-old primiparous woman at 27 gestational weeks with no medical or family history was referred for anemia associated with increased inflammatory markers. Medications included folic acid and oral iron therapy. The patient reported no symptoms, except for pruritus. Clinical examination revealed right-sided lymphadenopathy of the cervical anterior triangle. Laboratory examination showed microcytic normochromic anemia, hemoglobin 7.7 g/dL (normal >10.5), thrombocytosis 700 × 109/L (normal < 150), elevated C-reactive protein level 47.6 mg/L (normal <5), low serum albumin level 2.9 g/dL (normal >3.5), and normal blood electrolytes, creatinine level, liver functions tests, and lactate dehydrogenase (LDH) levels. Cervicothoracic magnetic resonance imaging (MRI) showed mediastinal and right-sided anterior cervical lymphadenopathies (size of the largest lymph nodes 6.1 × 3.2 × 6.7cm and 1.5 × 2.7 × 3.0 cm, respectively). Cervical lymph node biopsy led to a diagnosis of nodular sclerosis classical Hodgkin lymphoma. The patient had stage IIA disease according to as Ann Arbor/Cotswold. A suspected lesion of the pons on cervical spine images prompted brain MRI showing a hyperintense signal in the central pons on T2-weighted and fluid attenuated inversion recovery (FLAIR) images, with restriction in diffusion-weighted imaging (DWI), without contrast enhancement (Figure), highly suggestive of central pontine myelinolysis. She was given 6 cycles of ABVD chemotherapy combining adriamycin, bleomycin, vinblastine, and dacarbazine during pregnancy. At 36 gestational weeks, a healthy infant was born. Interim positron emission tomography (PET) performed after 2 and 4 cycles as well as at the end of chemotherapy showed complete metabolic response (Deauville 1). Brain MRI following treatment completion also showed complete remission of the pontine lesion. We report here a case of asymptomatic central pontine myelinolysis in a pregnant woman with Hodgkin lymphoma. Osmotic demyelination syndrome including central pontine myelinolysis and extrapontine myelinolysis is a rare demyelinating disease of the pons typically occurring after rapid correction of severe hyponatremia in patients with nutritional or electrolyte stress, alcoholism, malnutrition, and immunosuppression.1Fitts W Vogel AC Mateen FJ. The changing face of osmotic demyelination syndrome: a retrospective, observational cohort study.Neurol Clin Pract. 2021; 11: 304-310Crossref PubMed Scopus (9) Google Scholar Clinical manifestations include encephalopathy then severe deterioration with dysphagia or dysarthria, oculomotor dysfunction, and potentially lethal tetraparesis. Unexplained and asymptomatic cases have been rarely described but are possible as in the present case.1Fitts W Vogel AC Mateen FJ. The changing face of osmotic demyelination syndrome: a retrospective, observational cohort study.Neurol Clin Pract. 2021; 11: 304-310Crossref PubMed Scopus (9) Google Scholar,2Doni E Tremolizzo L Patassini M Pioltelli PE Ferrarese C Appollonio I. Asymptomatic central pontine myelinolysis without hyponatremia in diffuse large B cell lymphoma.Neurol Sci. 2016; 37: 2035-2037Crossref PubMed Scopus (6) Google Scholar The pathophysiology of osmotic demyelination syndrome remains controversial. It involves damage to the myelin sheath of nerve cells in the brainstem, resulting from the physiologic imbalance of osmoles within the brain in regions most susceptible to osmotic stress. Diagnosis of osmotic demyelination syndrome relies on imaging.1Fitts W Vogel AC Mateen FJ. The changing face of osmotic demyelination syndrome: a retrospective, observational cohort study.Neurol Clin Pract. 2021; 11: 304-310Crossref PubMed Scopus (9) Google Scholar CT scan can be normal within the 2 first weeks, but MRI can detect lesions with the 24 first hours with T2-weighted and FLAIR images showing symmetric hyperintense signals and T1 weighted-images displaying hypointense and noncontrast enhancing lesions. Osmotic demyelination syndrome cases reported in patients with hematological malignancies such as non-Hodgkin lymphoma and Hodgkin lymphoma are rare and can present as an incidental finding resolving after chemotherapy.2Doni E Tremolizzo L Patassini M Pioltelli PE Ferrarese C Appollonio I. Asymptomatic central pontine myelinolysis without hyponatremia in diffuse large B cell lymphoma.Neurol Sci. 2016; 37: 2035-2037Crossref PubMed Scopus (6) Google Scholar,3Loizou LA Rokos J. Central pontine myelinolysis in association with Hodgkin's lymphoma.Postgrad Med J. 1981; 57: 324-328Crossref PubMed Scopus (10) Google Scholar It has also been reported during pregnancy in a context of hyperemesis, related to hyponatremia, hypokalemia, salt restricted diet, magnesium administration, thiamine deficiency, and drugs.4Sánchez-Ferrer ML Prieto-Sánchez MT Orozco-Fernández R Machado-Linde F Nieto-Diaz A. Central pontine myelinolysis during pregnancy: pathogenesis, diagnosis and management.J Obstet Gynaecol. 2017; 37: 273-279Crossref PubMed Scopus (7) Google Scholar,5Gosavi TD See SJ. Central pontine myelinolysis presenting as isolated sixth nerve palsy in third trimester of pregnancy.Ann Indian Acad Neurol. 2015; 18: 84-86PubMed Google Scholar and sometimes unexplained with resolution after delivery.5Gosavi TD See SJ. Central pontine myelinolysis presenting as isolated sixth nerve palsy in third trimester of pregnancy.Ann Indian Acad Neurol. 2015; 18: 84-86PubMed Google Scholar Whether central pontine myelinolysis was related to pregnancy, lymphoma, or both in our patient is disputed. In conclusion, clinicians should be aware that lymphoma or pregnancy per se could predispose to central pontine myelinolysis, through currently unknown mechanisms.

Background and purpose: The aim of our study is to present, for the first time, the clinical, radiological, and neurocognitive characteristics of Greek adult patients with Moyamoya disease (MMD). Methods: We analyzed prospectively collected data of 12 patients referred to our department from 2004 to 2019. All patients underwent a thorough diagnostic work up, including extensive clinical, neuroradiological, and neurocognitive assessment. Results: Our study population consisted of 7 females and the median age at the time of the diagnosis was 43.5 years. No patient had a positive family history of the disease and roughly 50% were hypertensives. Ten patients presented with transient or permanent cerebrovascular ischemia and two patients suffered from hemorrhagic complications. The median NIHSS was 7.5 (0–23) and clinical status remained stable during follow-up with conservative treatment in most of the patients. The majority (83.3%) had bilateral disease confirmed by DSA. All lesions exclusively affected the anterior circulation, with 50% of patients presenting with stenoocclusive changes. No aneurysm or AVM were revealed. The most common neurocognitive deficits were in the executive and language domains. Conclusions: Our MMD patients had a later onset of the disease and an absence of familial occurrence. The most common manifestation was ischemia, transient or permanent, and all lesions affected the anterior circulation, whereas no vascular malformations (AVM, aneurysms) were demonstrated in brain imaging. These findings in Greek patients imply a probable different, Mediterranean phenotype.

The aim of this study was to measure the one-year total cost of strokes and to investigate the value of stroke care, defined as cost per QALY. The study population included 892 patients with first-ever acute strokes, hemorrhagic strokes, and ischemic strokes, (ICD-10 codes: I61, I63, and I64) admitted within 48 h of symptoms onset to nine public hospitals located in six cities. We conducted a bottom-up cost analysis from the societal point of view. All cost components including direct medical costs, productivity losses due to morbidity and mortality, and informal care costs were considered. We used an annual time horizon, including all costs for 2021, irrespective of the time of disease onset. The average cost (direct and indirect) was extrapolated in order to estimate the national annual burden associated with stroke. We estimated the total cost of stroke in Greece at EUR 343.1 mil. a year in 2021, (EUR 10,722/patient or EUR 23,308 per QALY). Out of EUR 343.1 mil., 53.3% (EUR 182.9 mil.) consisted of direct healthcare costs, representing 1.1% of current health expenditure in 2021. Overall, productivity losses were calculated at EUR 160.2 mil. The mean productivity losses were estimated to be 116 work days with 55.1 days lost due to premature retirement and absenteeism from work, 18.5 days lost due to mortality, and 42.4 days lost due to informal caregiving by family members. This study highlights the burden of stroke and underlines the need for stakeholders and policymakers to re-organize stroke care and promote interventions that have been proven cost-effective.

Introduction: High-quality evidence regarding the use of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO) has been provided by recently completed randomized controlled clinical trials (RCTs). Methods: We conducted a systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of EVT in addition to best medical treatment (BMT) versus BMT alone for BAO. The random-effects model was used, while the fragility index (FI) was calculated for dichotomous outcomes of interest. Results: Four RCTs were included comprising a total of 988 patients with acute BAO (mean age: 65.6 years, 70% men, median NIHSS: 24, 39% pretreatment with intravenous thrombolysis). EVT was related to higher likelihood of good functional outcome (RR: 1.54; 95% CI: 1.16–2.05; I2 = 60%), functional independence (RR: 1.83; 95% CI: 1.08–3.08; I2 = 79%) and reduced disability at 3 months (adjusted common OR: 1.96; 95% CI: 1.26–3.05; I2 = 59%) compared to BMT alone. Despite that EVT was associated with a higher risk for symptomatic intracranial hemorrhage (RR: 7.78; 95% CI: 2.36–25.61; I2 = 0%) and any intracranial hemorrhage (RR: 2.85; 95% CI: 1.50–5.44; I2 = 16%), mortality at 3 months was lower among patients that received EVT plus BMT versus BMT alone (RR: 0.76; 95% CI: 0.65–0.89; I2 = 0%). However, sufficient robustness was not evident in any of the reported associations (FI < 10) including the overall effect regarding the primary outcome. The former associations were predominantly driven by RCTs with recruitment limited in China. Conclusions: EVT combined with BMT is associated with a higher likelihood of achieving good functional outcomes and a lower risk of death at 3 months compared to BMT alone, despite the higher risk of sICH. An individual-patient data meta-analysis is warranted to uncover and adjust for potential sources of heterogeneity and to provide further insight.

Research investigating pragmatic deficits in individuals with right hemisphere damage focuses on identifying the potential mechanisms responsible for the nature of these impairments. Nonetheless, the presumed shared cognitive mechanisms that could account for these deficits have not yet been established through data-based evidence from lesion studies. This study aimed to examine the co-occurrence of pragmatic language deficits, Theory of Mind impairments, and executive functions while also exploring their associations with brain lesion sites. Twenty-five patients suffering from unilateral right hemisphere stroke and thirty-seven healthy participants were recruited for this study. The two groups were tested in pragmatics, Theory of Mind, and executive function tasks. Structural imaging data were also obtained for the identification of the lesion sites. The findings of this study suggest a potential convergence among the three aforementioned cognitive mechanisms. Moreover, we postulate a hypothesis for a neural circuitry for communication impairments observed in individuals with right hemisphere damage.

Background and purposeOrolingual angioedema (OA) represents a rare but life-threatening complication among patients with acute ischemic stroke treated with intravenous thrombolysis with alteplase. Novel agents, including icatibant, are recommended in resistant patients with alteplase-induced OA who have failed to respond to first-line therapies including corticosteroids, antihistamines, and/or adrenaline.MethodsWe present a patient with alteplase-induced OA who showed substantial clinical improvement following the administration of icatibant.ResultsWe describe a 71-year-old woman with known arterial hypertension under treatment with angiotensin-converting enzyme inhibitor, who presented with acute ischemic stroke in the territory of the right middle cerebral artery and received intravenous alteplase. During intravenous thrombolysis, the case was complicated with OA without any response to standard anaphylactic treatment including corticosteroids, dimetindene, and adrenaline. Thirty minutes after symptom onset, icatibant, a synthetic selective bradykinin B2-receptor antagonist, was administered subcutaneously. Substantial symptomatic resolution was observed only following the icatibant administration.ConclusionsThis case highlights the effectiveness of icatibant in the acute management of alteplase-induced OA. In particular, icatibant administration, following first-line therapies including corticosteroids, antihistamines, and/or adrenaline, may avert tracheostomy and intubation in resistant and refractory cases with OA following intravenous thrombolysis for acute ischemic stroke.

To assess stroke patient-reported experiences and hospital staff experiences, during hospital stay. METHODS:Stroke patient-reported experiences (n=387) were recorded using the translated and culturally adapted NHS-Stroke Questionnaire into Greek and staff experiences (n=236) were investigated using the Compassion Satisfaction and Burnout subscales of the ProQOL questionnaire. RESULTS:Staff's mean compassion satisfaction score was 39.2 (SD=6.3) and mean burnout score was 24.3 (SD=5.6). Only 38.5% of the staff stated that there is smooth cooperation with healthcare professionals of other specialties/disciplines. Personnel working in an NHS Hospital was more satisfied and less burned-out when compared to personnel working at a University Hospital (p=0.02 and p<0.001, respectively). Mean total patient-reported experiences score was 81.9 (SD=9.5). Bivariate analysis revealed statistically significant differences for total patient-reported experiences among the eight study hospitals (p>0.001). CONCLUSIONS:Health policy planners and decision-makers must take into consideration the results of such self-reported measures to establish innovative techniques to accomplish goals such as staff-specialization, continuous training and applying formal frameworks for efficient cooperation amongst different disciplines.

The aim of this study was to present the descriptive characteristics of the Stroke Units Necessity for Patients (SUN4P) registry.METHODS:The study population derived from the web-based SUN4P registry included 823 patients with first-ever acute stroke. Descriptive statistics were used to present patients' characteristics.RESULTS:The vast majority of patients (80.4%) had an ischemic stroke, whereas 15.4% had a hemorrhagic stroke. Hypertension was the leading risk factor in both patients. The patients with ischemic stroke had higher prevalence of traditional cardiovascular risk factors such as diabetes mellitus, dyslipidemia and smoking and most commonly cryptogenic stroke (39%). National Institutes of Health Stroke Scale (NIHSS) was higher among patients with hemorrhagic in comparison to those with ischemic stroke (10.5 vs 6 respectively). Moreover, all patients had similar rate of disability prior to stroke, as shown by Modified Rankin Scale (mRS=0).CONCLUSIONS:These data are in accordance with current evidence and should be thoroughly assessed in order to ensure optimal therapeutic management of stroke patients.

The aim of this study was to calculate the average operational cost per sub-type of stroke patient and to investigate cost drivers (e.g. ALoS, NIHSS score, age) correlated to cost.METHODS:Direct medical costs (diagnostic imaging and clinical laboratory exams, overheads/bed cost, pharmaceuticals, ringers and other non-durables and inpatient rehabilitation) per patient were calculated from the providers' (hospitals') perspective. Resource use data derived from the "SUN4P" web-based registry and unit costs were retrieved from publically available sources and were assigned to resource use.RESULTS:The sample comprised 6,282 inpatient days of 750 patients (mean age: 75.5±13.3 years) admitted from July 2019 to July 2021, in nine public hospitals. Mean length of stay was 8.4±7.6 days and mean total operational cost was calculated to €1,239.4 (from which 45% and 35% related to diagnostic exams and overheads/bed cost respectively). Mean cost related to hemorrhagic stroke patients that were discharged alive was calculated significantly higher compared to mean cost related to ischemic stroke patients who didn't undertake thrombolysis and were also discharged alive from the hospital (€2,155.2 vs. €945.2, p<0.001). Linear regression analysis revealed that length of stay was significantly correlated with cost (coefficient beta=232, 95% CI confidence interval = 220-243, p<0.001).CONCLUSIONS:These findings are in accordance with current evidence and should be thoroughly assessed to rationalize inpatient reimbursement rates in order to achieve improved value of care.