Neurological event prediction for patients with symptomatic cerebral cavernous malformation: the BLED2 score

OBJECTIVE Retrospective patient cohort studies have identified risk factors associated with recurrent focal neurological events in patients with symptomatic cerebral cavernous malformations (CCMs). Using a prospectively maintained database of patients with CCMs, this study identified key risk factors for recurrent neurological events in patients with symptomatic CCM. A simple scoring system and risk stratification calculator was then created to predict future neurological events in patients with symptomatic CCMs. METHODS This was a dual-center, prospectively acquired, retrospectively analyzed cohort study. Adult patients who presented with symptomatic CCMs causing focal neurological deficits or seizures were uniformly treated and clinically followed from the time of diagnosis onward. Baseline variables included age, sex, history of intracerebral hemorrhage, lesion multiplicity, location, eloquence, size, number of past neurological events, and duration since last event. Stepwise multivariable Cox regression was used to derive independent predictors of recurrent neurological events, and predictive accuracy was assessed. A scoring system based on the relative magnitude of each risk factor was devised, and Kaplan-Meier curve analysis was used to compare event-free survival among patients with different score values. Subsequently, 1-, 2-, and 5-year neurological event rates were calculated for every score value on the basis of the final model. RESULTS In total, 126 (47%) of 270 patients met the inclusion criteria. During the mean (interquartile range) follow-up of 54.4 (12–66) months, 55 patients (44%) experienced recurrent neurological events. Multivariable analysis yielded 4 risk factors: bleeding at presentation (HR 1.92, p = 0.048), large size ≥ 12 mm (HR 2.06, p = 0.016), eloquent location (HR 3.01, p = 0.013), and duration ≤ 1 year since last event (HR 9.28, p = 0.002). The model achieved an optimism-corrected c-statistic of 0.7209. All factors were assigned 1 point, except duration from last event which was assigned 2 points. The acronym BLED2 summarizes the scoring system. The 1-, 2-, and 5-year risks of a recurrent neurological event ranged from 0.6%, 1.2%, and 2.3%, respectively, for patients with a BLED2 score of 0, to 48%, 74%, and 93%, respectively, for patients with a BLED2 score of 5. CONCLUSIONS The BLED2 risk score predicts prospective neurological events in symptomatic CCM patients.

Self-reported safety of the BBIBP-CorV (Sinopharm) COVID-19 vaccine among Iranian people with multiple sclerosis

To affirm the short-term safety of the BBIBP-CorV (Sinopharm) COVID-19 vaccine among people with multiple sclerosis (pwMS), 517 vaccinated and 174 unvaccinated pwMS were interviewed. 16.2% of the vaccinated pwMS reported at least one neurological event in their respective at-risk periods (ARP), a period from the first until two weeks after the second vaccine dose. In a multivariable logistic regression model, presence of comorbidities (P = 0.01), being on natalizumab (P = 0.03), and experiencing post-vaccination myalgia (P < 0.01) predicted the development of post-vaccination neurological symptoms. One MS relapse, one COVID-19 contraction, and one ulcerative colitis flare after the first, and five MS relapses after the second dose, were the only reported serious adverse events during the ARPs. A multivariable Poisson regression model accounting for possible confounders failed to show any statistically-significant increase in relapse rates during the ARPs of vaccinated, compared to the prior year of unvaccinated pwMS (P = 0.78). Hence, the BBIBP-CorV vaccine does not seem to affect short-term MS activity. Furthermore, as 83.33% of the unvaccinated pwMS reported fear of possible adverse events to be the reason of their vaccination hesitancy; hence, provision of misinformed pwMS with evidence-based consultations in this regard is encouraged.

Occipito-temporal infarction manifesting as isolated visual perceptual abnormalities: A rare case of posterior cerebral artery stroke

Ischemic stroke in the Posterior Cerebral Artery (PCA) territory is an uncommon entity. Majority present with visual field defects while isolated visual perceptual abnormalities are an exceptional manifestation. About 60 year old hypertensive patient presented with vague symptoms of blurring of vision and palinopsia. Defective color vision was recorded in superior quadrants. Perimetry revealed bilateral congruous left superior quadrantanopia. Magnetic Resonance Imaging (MRI) disclosed right PCA infarct involving occipito-temporal region. This case highlights a rare presentation of PCA stroke with palinopsia and cerebral dyschromatopsia. Perimetric examination coupled with urgent neuroimaging helps the clinician in prompt diagnosis of neurological event causing unexplained visual phenomena.

OT and Cognition: Are We Limiting Our Scope of Practice? The Utilization of Cognitive Assessments Across a Health Care Campus Setting

Date Presented 04/22/21 OTs are trained to identify cognitive impairments in individuals diagnosed with specific diseases or who have sustained injuries or experienced a neurological event such as stroke. However, the presenters’ research demonstrates that OTs are underutilizing formal cognitive assessments and more often relying on observations and screening tools. Presenters discuss survey findings, setting influences, and potential solutions for OTs to increase the use of cognitive assessments in practice. Primary Author and Speaker: Amanda J. Blattman Contributing Authors: Jacqueline Schechter, Anne Spence, Susan S. Hayashi, Kara Sauerburger, Molly Houdeshell, Jennifer Henry, Judith Lieu, Robert Hayashi, and Allison King

MRI Brain Documentation

In many clinical cases, a patient may come to the hospital with a neurological abnormality. This patient happen to have a normal brain MRI study that is recorded on the Picture Archiving and Communicating system (PACs) of that hospital. The previous normal study will help in identifying any pathology take place in the future easily. What if all the patients did have a previous studies for the brain as some kind of documentation? It will help a lot. The aim of this paper is to propose a new idea that required for all the citizens in a country to have a normal brain MRI study recorded on their medical file and this MRI study updated every five years by undertaking an MRI scan. The usefulness of this idea can be imply in different ways. For example; when a patient affected by any type of neurological issue, we have a morphological documentation for the brain prior to that neurological event took a place. As well, this is will provide a database for researchers to find pre and post neurological event documentation. Furthermore, it will help in detecting and documenting senile atrophic changes over the time. Sometime patients will have a “silent stroke” which has no symptoms which can be detected by the brain MRI scan.

Acute aortic dissection with entry tear at the aortic arch: long-term outcome

OBJECTIVES The goal was to evaluate outcomes after conservative or surgical treatment of acute aortic arch dissections. METHODS Between January 2009 and December 2018, patients with a diagnosis of acute aortic dissection were analysed. Aortic arch aortic dissection was defined as a dissection with an isolated entry tear at the aortic arch with no involvement of the ascending aorta. RESULTS Aortic arch dissection was diagnosed in 31 patients (age 59 ± 11 years). Surgical intervention was performed in 13 (41.9%) cases. Overall in-hospital mortality was 3% (n = 1), and all deaths occurred in the conservative group (n = 1; 6%), whereas the overall stroke rate was 3% (n = 1), and all strokes occurred in the group treated surgically (n = 1; 8%). Surgical repair was necessary for the following conditions: end-organ malperfusion (n = 9; 69%), impending rupture (n = 3; 23%) and dilatation of the aorta with ongoing pain refractory to medical treatment (n = 1; 8%). Overall survival at the end of the follow-up period was 71%, with 77% in the surgical group and 63% in the conservative group (P = 0.91). Freedom from surgical intervention was 71%, with 82% in the surgical and 63% in the conservative group (P = 0.21), and freedom from a neurological event was 88%, with 89% versus 89% (P = 0.68) in the surgical and conservative groups, respectively. CONCLUSIONS Aortic arch dissection is a rare pathological condition that is one of the most challenging decision-making entities. Patients manifesting an uneventful course not requiring a surgical intervention during a hospital stay were at a higher risk for aorta-related intervention during the follow-up period. The treatment modality had no impact on survival or on the incidence of a neurological event.

Abstract 334: Evaluating Sedation Regimens and Time to Awakening in Post Cardiac Arrest Patients

Introduction: Guidelines for post-arrest care recommend use of short acting sedation, but there is currently significant practice variation. We tested whether benzodiazepine use was associated with delayed awakening in this population. Methods: We performed a retrospective cohort study at a large academic medical center including comatose patients hospitalized after resuscitation from in- or out-of-hospital cardiac arrest from January 2010 to September 2019. We excluded patients with cardiac arrest secondary to primary neurological event or trauma, those with severe cerebral edema on initial head imaging, those who were awake post-arrest and those with severe shock for whom benzodiazepines might have been chosen for hemodynamic reasons. We extracted all medication information from the electronic medical record and standard clinical and outcome information from a prospective registry maintained at our center. We considered patients to be exposed to benzodiazepines if they received > 10mg midazolam equivalents in the first 72 hours after cardiac arrest and censored cumulative mediation data at awakening for those who awakened before 72 hours. Our primary outcome of interest was days from arrest to awakening, which we defined as following verbal commands. We compared median time to awakening across sedation groups, then performed Cox regression to test the independent association of benzodiazepine exposure with time to awakening after adjusting for age, sex, weight, presenting rhythm, arrest location, initial serum creatinine, initial shock severity, initial neurological examination and presence of epileptiform. Results: Overall, 2,778 patients presented during the study period of which 621 met inclusion criteria for analysis and 209/621 (34%) awakened after a median of 4 [IQR 3 - 7] days. Patients who received benzodiazepines for sedation awakened significantly later than those who did not (5 days vs. 3 days, P=0.004). In adjusted regression, benzodiazepine exposure was independently associated with delayed awakening (adjusted hazard ratio 0.64 (95% CI 0.44 - 0.94)). Conclusion: Benzodiazepine exposure is associated with delayed awakening in comatose survivors of cardiac arrest.

Risk of Seizures after Immunization with Vaccine in Children

Adverse neurological event particularly seizure after vaccination is not uncommon. The most linked vaccines are Diphtheria, Pertussis and Tetanus toxoid (DPT), Measles, Mumps and Rubella (MMR) and other combination vaccines. It is documented that increased febrile seizure after DPT and MMR vaccine is due to increase febrile episodes precipitating seizure and it is time related. Concomitant administration of vaccines cause seizure due to synergistic effect of those vaccines. When these vaccines are given separately, the risk of seizure is decreased. These type of vaccines are MMR + varicella (MMRV), DTaP-HepB-IPV etc. Regarding etiology, genetic mutation is most important. Some genes are closely related to vaccine induced FS and afebrile seizure like SCN1A, SCN2A, IFI44L, PCDH19 etc. Other causes are endotoxin mediated endothelial damage, IL-1â production and non CNS infection. It is well evident that consequences of not giving vaccine are far more than the adverse events. So Vaccinations should be performed without contraindication in children with previous febrile and afebrile seizures with proper counseling. Bangladesh J Child Health 2020; VOL 44 (1) :40-47