Journal Of Clinical Neuroscience Research Articles

Publication patterns of posters and oral presentations at the Annual Meeting of the Joint AANS/CNS Cerebrovascular Section.

The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) Joint Cerebrovascular (CV) Section serves as a centralized entity for the dissemination of information related to CV neurosurgery. The quality of scientific conferences, such as the CV Section's Society of NeuroInterventional Surgery Annual Meeting, can be gauged by the number of poster and oral presentations that are published in peer-reviewed journals. However, publication rates from the CV Section's meetings are unknown. The objective of this study was to assess the rate at which abstracts presented at the AANS/CNS CV Section Annual Meeting from 2014 to 2018 were subsequently published in peer-reviewed journals. The abstract titles for all accepted poster and oral podium presentation abstracts from the 2014-2018 Annual Joint AANS/CNS CV Section Meetings were searched using PubMed. A match was defined as sufficient similarity between the abstract and its corresponding journal publication with regard to title, authors, methods, and results. Five-year impact factors (IFs) from Journal Citation Reports (JCR), the country of the corresponding author, and the number of citations in the Scopus database were obtained using the articles' digital object identifier when available, or the exact article title, journal, and year of publication. Of the 607 total poster and oral presentations from the 2014-2018 Annual Meetings of the AANS/CNS Joint CV Section, 46.29% (n = 281) have been published. Published articles received 3233 total citations for an average number of citations per article (± SD) of 10.89 ± 16.37. The average 5-year JCR IF of published studies was 4.64 ± 3.13. Additionally, 98.22% of published abstracts were in publication within 4 years from the time the abstract was presented. The most common peer-reviewed neurosurgical journals featuring these publications were the Journal of Neurosurgery, World Neurosurgery, the Journal of NeuroInterventional Surgery, Neurosurgery, and the Journal of Clinical Neuroscience. Nearly half of all poster and oral presentations at the annual meetings of the AANS/CNS Joint CV Section from 2014 to 2018 have been published in PubMed-indexed, peer-reviewed journals. The average number of citations per publication (10.89 ± 16.37) reflects the high quality of abstracts accepted for presentation. It is important to continuously assess the quality of research presented at national conferences to ensure that standards are being maintained for the advancement of clinical practice in a given area of medicine. Conference abstract publication rates in peer-reviewed journals represent a way in which research quality can be gauged, and the authors encourage others to conduct similar investigations in their subspecialty area of interest and/or practice.

Training Neurology Residents to Address Uncomfortable Patient Behavior Through a Simulated Experience (P8-2.002)

<h3>Objective:</h3> Evaluate how Neurology residents address a complaint of sexual harassment with a patient as the perpetrator. <h3>Background:</h3> Sexual harassment of medical providers is common. While hospitals typically have policies regarding harassment between employees, when the aggressor is a patient, the policies are not always clearly defined. Thus, clinicians may not have guidance on how to address inappropriate behavior from patients. <h3>Design/Methods:</h3> We developed an objective structured clinical examination (OSCE) in our simulation center for graduating Neurology residents. We trained a standardized professional (SP) to act as a junior resident who experienced verbal sexual harassment from a male patient. The learners were asked to elicit the complaint, provide counseling, and devise a plan. Faculty observers were present behind a one-way mirror glass and provided verbal feedback. The SP also gave verbal and written feedback using a standardized rubric. At the end of the encounter, the learners were provided an anonymous survey (1–5, least-most). <h3>Results:</h3> Fifteen residents participated in the OSCE. The SP gave full credit to all of the residents for their non-verbal communication and appropriate acknowledgement of her feelings. Six learners were given partial credit for mitigating the SP’s feeling of isolation. All but three learners were given full credit for collaborating with the SP to formulate a plan to treat the patient. Eight residents filled out a post-OSCE survey. On average, the learners were moderately prepared for the station (mean score 3.6±1.06), however they did find it to be very useful (mean score 4.5±0.76). All learners who filled out the survey felt that this OSCE should be repeated for future residents. <h3>Conclusions:</h3> OSCEs are a valuable and effective tool to assess how residents support a colleague when patients exhibit inappropriate behavior. This OSCE can be repeated for future residents to assess for trends in performance and perception. <b>Disclosure:</b> Dr. Sabadia has nothing to disclose. Dr. Kurzweil has nothing to disclose. Dr. Lillemoe has nothing to disclose. Dr. Lewis has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Seminars in Neurology. Dr. Lewis has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of Clinical Neuroscience. Dr. Pleninger has nothing to disclose. Dr. Giglio has nothing to disclose. Dr. Smith has nothing to disclose. The institution of Dr. Zakin has received research support from American Board of Psychiatry and Neurology. Sondra Zabar has nothing to disclose.

Teaching Neurology Trainees to Lead a Goals of Care Conversation using Simulation (P8-2.003)

<h3>Objective:</h3> To enhance neurology trainees’ comfort level in leading a goals of care conversation with a patient’s family member. <h3>Background:</h3> Physicians must utilize shared decision making regarding treatment options for patients with a stroke. This includes consideration of a patient’s values, as understood by their family members, to help direct treatment decisions. Currently, there is no standardized approach to educate neurology trainees on leading a goals of care conversation with patients and their family members. <h3>Design/Methods:</h3> We created an objective structured clinical examination in our simulation center for graduating neurology residents. We trained a standardized professional (SP) to play the role of a patient’s family member. The learners were asked to engage in a goals of care conversation with the SP. The patient had a hemorrhagic stroke and would require the insertion of a feeding tube to sustain life. Trainees were evaluated by the SP via a written checklist on their communication skills, explanation of distinct treatment options, and ability to perform shared decision making. An observing faculty member provided verbal feedback. <h3>Results:</h3> Fifteen residents participated in the OSCE. All residents received full credit for utilizing non-judgmental communication. Four residents received full credit for explaining the different treatment options available to the patient in a way the SP understood. Most residents felt well prepared for the station with a mean score of 4.125 (stdev 0.64). Most residents self-evaluated their performance to be above average with a mean score of 4 (stdev 0.53). All residents felt that the OSCE should be repeated for future classes. <h3>Conclusions:</h3> OSCEs are a powerful tool to hone communication skills. Our graduating neurology residents performed well on humanistic skills, but areas for improvement included discussing technical aspects of the scenario. This OSCE can be repeated for future neurology residents to improve their ability to communicate goals of care effectively. <b>Disclosure:</b> Dr. Giglio has nothing to disclose. Dr. Lewis has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Seminars in Neurology. Dr. Lewis has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of Clinical Neuroscience. Dr. Lillemoe has nothing to disclose. Dr. Pleninger has nothing to disclose. Dr. Sabadia has nothing to disclose. Dr. Smith has nothing to disclose. The institution of Dr. Zakin has received research support from American Board of Psychiatry and Neurology. Sondra Zabar has nothing to disclose. Dr. Kurzweil has nothing to disclose.

Use of Simulation to Develop Telestroke Skills in Trainees (S10.009)

<h3>Objective:</h3> To create an educational intervention to prepare neurology residents for telestroke encounters. <h3>Background:</h3> Telemedicine has become increasingly common in the post-COVID era and is now a part of most clinical practices. There is a need for residency training programs to incorporate telemedicine teaching into their curriculum. Telestroke is a well-established practice and way to bring neurovascular clinical expertise into settings where an in-person stroke specialist may not be available. Skills and professionalism important in a remote telestroke consult apply to all types of telemedicine encounters. <h3>Design/Methods:</h3> Our telestroke OSCE (objective structured clinical examination) case was developed by our neurology faculty in conjunction with a simulation specialist. Two standardized actors were trained to impersonate an acute stroke patient and a bedside provider in an emergency room setting. The neurology resident learner was in a separate room and acted as a stroke specialist, communicating with the standardized actors and conducting an NIHSS using a live video interface. Following the encounter, immediate feedback was given by a faculty observer and the standardized actor rated resident performance using a checklist. After OSCEs were completed, the residents were debriefed in a group setting and a learner feedback survey was collected (1–5, least-most). <h3>Results:</h3> Out of 15 resident participants, 8 completed the learner survey (53%). They reported feeling fairly well-prepared for the OSCE (4±0.5) and rated their performance overall well (4.3±0.5). Many learners identified instructing the standardized remote provider in the NIHSS virtually as the most challenging aspect in the encounter. All learners indicated that this OSCE should be repeated for future residency classes. <h3>Conclusions:</h3> We demonstrated that a telestroke simulation is a useful tool to directly observe residents, offer immediate feedback and review telemedicine best-practices. It is a feasible, valued and important part of our dynamic neurology residency curriculum. <b>Disclosure:</b> Dr. Lillemoe has nothing to disclose. Dr. Kurzweil has nothing to disclose. Dr. Sabadia has nothing to disclose. Dr. Pleninger has nothing to disclose. Dr. Lewis has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Seminars in Neurology. Dr. Lewis has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of Clinical Neuroscience. Dr. Giglio has nothing to disclose. Sondra Zabar has nothing to disclose.

Teaching Neurology Trainees to Provide a Terminal Diagnosis Using Objective Structured Clinical Examinations (OSCE) (P1-2.004)

<h3>Objective:</h3> To prepare neurology resident to deliver news of a terminal illness through use of simulation. <h3>Background:</h3> Ensuring trainee competency in communication with patients is required by the ACGME. Delivering bad news is a particularly challenging but essential communication skill to master. Various methods are used to teach and assess resident competency on this topic, but the best way to teach this skill, particularly when the neurologic diagnosis is terminal, is unclear. <h3>Design/Methods:</h3> We developed an objective structured clinical examination (OSCE) in our simulation center that focused on delivering news to a patient about a terminal neuromuscular illness. Third-year neurology residents (N=15) interacted with a standardized professional (SP) playing a patient presenting to discuss the results of his electro diagnostic study showing evidence of amyotrophic lateral sclerosis. Residents received feedback from faculty observers and the SP regarding their ability to develop a relationship with the patient, communicate bad news effectively, and provide adequate education and counseling. Additionally, residents were surveyed about the value of their experience (scale 1–5, least to most). <h3>Results:</h3> A majority of residents completed a post-OSCE questionnaire (N=8, 53%). Most felt unprepared (2.87±0.99), though the majority found the OSCE useful (4.37±0.91). The SP felt that most residents acknowledged feelings and emotions appropriately (91%), provided clear explanations and information (84%), collaborated to plan for next steps (77%), identified an immediate support system (75%), and helped the SP understand the nature of their symptoms (77%). However, residents less frequently prepared the SP for the news by giving a “warning shot” (64%). <h3>Conclusions:</h3> Simulation is a powerful tool that allows residents to learn through an interactive experience, direct observation, and timely feedback. We have demonstrated the feasibility of utilizing simulation in training residents to deliver a diagnosis of a terminal neurologic illness, and that this method is well received by trainees. <b>Disclosure:</b> Dr. Smith has nothing to disclose. Dr. Lewis has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Seminars in Neurology. Dr. Lewis has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of Clinical Neuroscience. Dr. Pleninger has nothing to disclose. Dr. Lillemoe has nothing to disclose. Dr. Sabadia has nothing to disclose. Dr. Giglio has nothing to disclose. Sondra Zabar has nothing to disclose. The institution of Dr. Zakin has received research support from American Board of Psychiatry and Neurology. Dr. Kurzweil has nothing to disclose.

COMMON PRESENTATION WITH AN UNCOMMON ETIOLOGY: THYMOMA-ASSOCIATED AUTOIMMUNE ENCEPHALITIS INDUCED BY COVID-19 BOOSTER VACCINE

SESSION TITLE: Issues After COVID-19 Vaccination Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: Thymoma-associated autoimmune encephalitis (TAAE) is an understudied and overlooked diagnosis in patients presenting with abrupt altered mental status. Described as inflammation of brain tissue, autoimmune encephalitis is seen in 5-10 cases per 100,000 across all age groups per year. A rare subtype involves neuronal surface antibodies to alpha-amino-3-hydroxyl-5-methyl-4isoxazolepropionic acid receptors (AMPA-R) encephalitis is seen even less commonly. Given the "unicorn” nature of presenting cases and difficulty of diagnosis, prompt identification and treatment are critical as prolonged courses without treatment are irreversible and deadly.CASE PRESENTATION: A 47-year-old male with no past medical history presented 3 days after a Johnson & Johnson coronavirus-2019 (COVID-19) booster vaccine due to worsening acute altered mental status over the past week. He complained of episodes of fever & chills prior to this. The patient's wife reported abrupt changes in memory and personality. Upon admission, the patient had a Glasgow Coma Scale of 4. The patient was intubated and transferred to the intensive care unit. Intravenous (IV) vancomycin, ceftriaxone and acyclovir was initiated for meningitis. Computed tomography (CT) scan of the head without contrast was unremarkable. Magnetic resonance imaging (MRI) showed enhancements of the right anterior and medial temporal lobe suggesting encephalitis. Cerebrospinal fluid analysis (CSF) revealed lymphocytic pleocytosis. A CT scan of the chest, abdomen and pelvis showed an anterior mediastinal mass measured 1.8 x 2.3 cm (Figure 1). FilmArray Meningitis polymerase chain reaction was negative as well as Herpes Simplex Virus (HSV) 1 and 2. Autoimmune encephalitis antibody was positive for Anti-AMPAR. Pulse dose steroids and intravenous immunoglobulin were initiated but failed. Rituximab was initiated and cardiothoracic surgery completed a thymectomy.DISCUSSION: TAAE is a rare disease, permanently debilitating, and deadly if unrecognized or treatment is delayed. Autoimmune encephalitis is an umbrella disease process seen in 0.00005% of patients per year. AMPA-R positive encephalitis is even less commonly seen with only 22 cases reported between the years 2009 and 2014 [1]. A rapidly progressive cognitive decline or psychiatric disorders are early features of this disease.Our patient had prodromal symptoms of fever and cognitive decline days after receiving his COVID-19 booster vaccine.CONCLUSIONS: Post-vaccine encephalomyelitis has been described in other settings[2]. This patient was free of symptoms prior to the COVID-19 vaccine booster, and demonstrated altered mental status hours after receiving it. This furthers the possibility of an association of the COVID-19 booster vaccine, development of encephalitis, and in this case a thymoma. Despite this, conclusions can not be made on the account of one report, but introduces a new area of focus to study.Reference #1: Höftberger, R., van Sonderen, A., Leypoldt, F., Houghton, D., Geschwind, M., Gelfand, J., Paredes, M., Sabater, L., Saiz, A., Titulaer, M. J., Graus, F., & Dalmau, J. (2015). Encephalitis and AMPA receptor antibodies: Novel findings in a case series of 22 patients. Neurology, 84(24), 2403–2412. https://doi.org/10.1212/WNL.0000000000001682Reference #2: Huynh, W., Cordato, D. J., Kehdi, E., Masters, L. T., & Dedousis, C. (2008). Post-vaccination encephalomyelitis: literature review and illustrative case. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 15(12), 1315–1322. https://doi.org/10.1016/j.jocn.2008.05.002DISCLOSURES: No relevant relationships by Matthew FrankNo relevant relationships by Justin IlaganNo relevant relationships by Danielle MahonNo relevant relationships by Danielle MahonNo relevant relationships by Harshini SahaniNo relevant relationships by Kameron TavakolianNo relevant relationships by Ndausung Udongwo SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Thymoma-associated autoimmune encephalitis (TAAE) is an understudied and overlooked diagnosis in patients presenting with abrupt altered mental status. Described as inflammation of brain tissue, autoimmune encephalitis is seen in 5-10 cases per 100,000 across all age groups per year. A rare subtype involves neuronal surface antibodies to alpha-amino-3-hydroxyl-5-methyl-4isoxazolepropionic acid receptors (AMPA-R) encephalitis is seen even less commonly. Given the "unicorn” nature of presenting cases and difficulty of diagnosis, prompt identification and treatment are critical as prolonged courses without treatment are irreversible and deadly. CASE PRESENTATION: A 47-year-old male with no past medical history presented 3 days after a Johnson & Johnson coronavirus-2019 (COVID-19) booster vaccine due to worsening acute altered mental status over the past week. He complained of episodes of fever & chills prior to this. The patient's wife reported abrupt changes in memory and personality. Upon admission, the patient had a Glasgow Coma Scale of 4. The patient was intubated and transferred to the intensive care unit. Intravenous (IV) vancomycin, ceftriaxone and acyclovir was initiated for meningitis. Computed tomography (CT) scan of the head without contrast was unremarkable. Magnetic resonance imaging (MRI) showed enhancements of the right anterior and medial temporal lobe suggesting encephalitis. Cerebrospinal fluid analysis (CSF) revealed lymphocytic pleocytosis. A CT scan of the chest, abdomen and pelvis showed an anterior mediastinal mass measured 1.8 x 2.3 cm (Figure 1). FilmArray Meningitis polymerase chain reaction was negative as well as Herpes Simplex Virus (HSV) 1 and 2. Autoimmune encephalitis antibody was positive for Anti-AMPAR. Pulse dose steroids and intravenous immunoglobulin were initiated but failed. Rituximab was initiated and cardiothoracic surgery completed a thymectomy. DISCUSSION: TAAE is a rare disease, permanently debilitating, and deadly if unrecognized or treatment is delayed. Autoimmune encephalitis is an umbrella disease process seen in 0.00005% of patients per year. AMPA-R positive encephalitis is even less commonly seen with only 22 cases reported between the years 2009 and 2014 [1]. A rapidly progressive cognitive decline or psychiatric disorders are early features of this disease.Our patient had prodromal symptoms of fever and cognitive decline days after receiving his COVID-19 booster vaccine. CONCLUSIONS: Post-vaccine encephalomyelitis has been described in other settings[2]. This patient was free of symptoms prior to the COVID-19 vaccine booster, and demonstrated altered mental status hours after receiving it. This furthers the possibility of an association of the COVID-19 booster vaccine, development of encephalitis, and in this case a thymoma. Despite this, conclusions can not be made on the account of one report, but introduces a new area of focus to study. Reference #1: Höftberger, R., van Sonderen, A., Leypoldt, F., Houghton, D., Geschwind, M., Gelfand, J., Paredes, M., Sabater, L., Saiz, A., Titulaer, M. J., Graus, F., & Dalmau, J. (2015). Encephalitis and AMPA receptor antibodies: Novel findings in a case series of 22 patients. Neurology, 84(24), 2403–2412. https://doi.org/10.1212/WNL.0000000000001682 Reference #2: Huynh, W., Cordato, D. J., Kehdi, E., Masters, L. T., & Dedousis, C. (2008). Post-vaccination encephalomyelitis: literature review and illustrative case. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 15(12), 1315–1322. https://doi.org/10.1016/j.jocn.2008.05.002 DISCLOSURES: No relevant relationships by Matthew Frank No relevant relationships by Justin Ilagan No relevant relationships by Danielle Mahon No relevant relationships by Danielle Mahon No relevant relationships by Harshini Sahani No relevant relationships by Kameron Tavakolian No relevant relationships by Ndausung Udongwo

New Editors-in-Chief team for Journal of Clinical Neuroscience

New Editors-in-Chief team for Journal of Clinical Neuroscience

A CASE OF OSA IN A PATIENT WITH A VENTRICULO-PERITONEAL SHUNT: A REAL HEADACHE

SESSION TITLE: Medical Student/Resident Sleep Disorders Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The patient is a 65 year old female who presented to the pulmonology clinic for management of her Obstuctive Sleep Apnea Syndrome (OSAS). She had been diagnosed with OSAS in early 2017 after a sleep study at an external facility and had been prescribed a Continuous Positive Airway Pressure (CPAP) Machine fitted with an oro-nasal mask. She had not been able to use the CPAP due to recurrent headaches and nasal congestion associated with use. CASE PRESENTATION: The patient was diagnosed with pseudotumo- cerebri after a motor vehicle accident in 2004. A right-sided ventricular shunt catheter (VP shunt) was placed in 2005. Her nausea, dizziness and frequent headaches subsequently resolved. In the interim she had been following up with her neurosurgeon and primary care physician on a regular basis and remained symptom free. She had a past medical history of mild intermittent asthma, pulmonary artery hypertension and hypertension which were well controlled with medical management. Five months after starting to use the CPAP machine she presented to her neurosurgeon with symptoms of dizziness, headaches and gait instability. Visit records were obtained with the patients consent and it was noted the neurological exam at the time was unremarkable and opthalmoscopic inspection did not show any evidence of papilledema. The Ventriculo-Peritoneal (VP) shunt was interrogated at the time and found to be functioning optimally. She was referred for a Computed Tomography (CT) scan of the head and a shunt study. CT head after showed the right frontal shunt catheter in position with a decrease in volume of the right lateral ventricle, there was no evidence of hemorrhage, hydrocephalus or extra-axial fluid. The shunt study showed no evidence of kinking or obstruction in the catheter along its course from the right lateral aspect of the cranium, over the right neck and right hemithorax up to the left abdomen overlying the left sacroiliac joint. The concurrent initiation of her symptoms with starting CPAP machine use warranted enquiry. The patient visited the pulmonology clinic 4 months later. In the interim she had stopped using the CPAP machine and her headaches, dizziness and gait instability had resolved, albeit her OSAS was uncontrolled. DISCUSSION: In view of the unremarkable CT of the head and normal shunt study the patients symptoms were attributed to external compression of the VP shunt by the securing straps of the oro-nasal attachment for the CPAP machine. This periodic occlusion could lead to an intermittent intracranial hypertension, which manifests as dizziness and gait instability with headaches. The intermittent nature of the obstruction resulted in the absence of ventriculomegaly on CT and the normal shunt study. CONCLUSIONS: The patient was fitted with a Dental appliance(Mandibular advancement device/ tongue retaining mouthpiece) for management of her OSAS and her symptoms resolved. Reference #1: Chee, B. N. H., Jalil, M. F. A., & Bulluss, K. J. (2016). Spontaneous pneumocephalus from nasal continuous positive airway pressure in a patient with ventriculo-peritoneal shunt. Journal of Clinical Neuroscience, 34, 215–217. doi: 10.1016/j.jocn.2016.05.040 Reference #2: Salem-Memou, S., Vallee, B., Jacquesson, T., Jouanneau, E., & Berhouma, M. (2016). Pathogenesis of Delayed Tension Intraventricular Pneumocephalus in Shunted Patient: Possible Role of Nocturnal Positive Pressure Ventilation. World Neurosurgery, 85. doi: 10.1016/j.wneu.2015.09.001 Reference #3: Jones, R., Davis, E. M., & Coleman, J. (2016). Pneumocephalus Secondary to CPAP in Setting of Remote Craniofacial Trauma. Chest, 150(4). doi: 10.1016/j.chest.2016.08.276 DISCLOSURES: No relevant relationships by Matthew Castillo, source=Web Response No relevant relationships by Abhishek Chakraborti, source=Web Response No relevant relationships by Erum Zahid, source=Web Response

Correction to: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

HomeStrokeVol. 49, No. 3Correction to: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection to: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association Originally published1 Mar 2018https://doi.org/10.1161/STR.0000000000000163Stroke. 2018;49:e138This article corrects the following2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke AssociationIn the article by Powers et al, “2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association,” which published ahead of print January 24, 2018, and appeared in the March 2018 issue of the journal (Stroke. 2018;49:e46–e110. DOI: 10.1161/STR.0000000000000158), a few corrections were needed.On page e46, the text above the byline read:Reviewed for evidence-based integrity and endorsed by the American Association of Neurological Surgeons and Congress of Neurological SurgeonsEndorsed by the Society for Academic Emergency MedicineIt has been updated to read:Reviewed for evidence-based integrity and endorsed by the American Association of Neurological Surgeons and Congress of Neurological SurgeonsEndorsed by the Society for Academic Emergency Medicine and Neurocritical Care SocietyThe American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists.On page e60, in the section “2.2. Brain Imaging,” in the knowledge byte text below recommendation 12:• The seventh sentence read, “Therefore, only the eligibility criteria from these trials should be used for patient selection.” It has been updated to read, “Therefore, only the eligibility criteria from one or the other of these trials should be used for patient selection.”• The eighth sentence read, “…at this time, the DAWN and DEFUSE 3 eligibility should be strictly adhered to in clinical practice.” It has been updated to read, “…at this time, the DAWN or DEFUSE 3 eligibility should be strictly adhered to in clinical practice.”On page e73, in the section “3.7. Mechanical Thrombectomy,” recommendation 8 read, “In selected patients with AIS within 6 to 24 hours….” It has been updated to read, “In selected patients with AIS within 16 to 24 hours….”On page e73, in the section “3.7. Mechanical Thrombectomy,” in the knowledge byte text below recommendation 8:• The seventh sentence read, “Therefore, only the eligibility criteria from these trials should be used for patient selection.” It has been updated to read, “Therefore, only the eligibility criteria from one or the other of these trials should be used for patient selection.”• The eighth sentence read, “…at this time, the DAWN and DEFUSE-3 eligibility should be strictly adhered to in clinical practice.” It has been updated to read, “…at this time, the DAWN or DEFUSE-3 eligibility should be strictly adhered to in clinical practice.”On page e76, in the section “3.10. Anticoagulants,” in the knowledge byte text below recommendation 1, the third sentence read, “...(LMWH, 64.2% versus aspirin, 6.52%; P=0.33).199” It has been updated to read, “...(LMWH, 64.2% versus aspirin, 62.5%; P=0.33).199”These corrections have been made to the current online version of the article, which is available at http://stroke.ahajournals.org/lookup/doi/10.1161/STR.0000000000000158. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Fernandes J (2022) Artificial Intelligence in Telemedicine Artificial Intelligence in Medicine, 10.1007/978-3-030-64573-1_93, (1219-1227), . Batra A, Verma A, Vishen A, Haldar M, Jaiswal S, Ahuja R, Sheikh W, Khatai A, Khanna P and Sarda S (2022) Rapid Thrombolysis Protocol: Results from a Before-and-after Study, Indian Journal of Critical Care Medicine, 10.5005/jp-journals-10071-24217, 26:5, (547-552), Online publication date: 30-Apr-2022. 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Wu L, Rajah G, Cosky E, Wu X, Li C, Chen J, Zhao W, Wu D, Ding Y and Ji X (2021) Outcomes in Endovascular Therapy for Basilar Artery Occlusion: Intracranial Atherosclerotic Disease vs. Embolism, Aging and disease, 10.14336/AD.2020.0704, 12:2, (404), . 张 作 (2021) Effect of Early Intensive Drug Therapy on Atherosclerotic Cerebral Infarction with Dysphagia, International Journal of Psychiatry and Neurology, 10.12677/IJPN.2021.102002, 10:02, (7-12), . Angerová Y, Maršálek P, Chmelová I, Gueye T, Barták M, Uherek Š, Bříza J and Rogalewicz V (2021) Cost analysis of early rehabilitation after stroke in comprehensive cerebrovascular centres in the Czech Republic, Central European Journal of Public Health, 10.21101/cejph.a6111, 29:2, (153-158), Online publication date: 30-Jun-2021. Ito Y, Kojima T, Sato N, Oinuma M, Horiuchi K, Ichikawa T, Oda K, Maeda T and Saito K (2021) Results of Mechanical Thrombectomy 6 Hours after Stroke Onset: Analysis of Multiple Stroke Centers in Fukushima Prefecture, Journal of Neuroendovascular Therapy, 10.5797/jnet.oa.2020-0007, 15:4, (220-227), . Vasquez H, Prasad L, Moscote-Salazar L and Agrawal A (2021) Atmospheric variables and subarachnoid hemorrhage: narrative review, Egyptian Journal of Neurosurgery, 10.1186/s41984-021-00102-4, 36:1, Online publication date: 1-Dec-2021. Sharma R, Nalleballe K, Kapoor N, Dandu V, Veerapaneni K, Yadala S, Jasti M, Siddamreddy S, Onteddu S and Brown A (2021) Telestroke: A New Paradigm Ischemic Stroke, 10.5772/intechopen.92831 N.K. S, B.H. G, Kachapur C and Kulkarni S (2021) Correlation of Platelet Indices with Severity of Acute Ischemic Stroke in Non-Diabetic and NonHypertensive Patients in Hubli, Karnataka, Journal of Evidence Based Medicine and Healthcare, 10.18410/jebmh/2021/561, 8:33, (3078-3083), Online publication date: 16-Aug-2021. Gutierrez S, Co C, Trias E and Pineda-Franks M (2021) Symptomatic Intracerebral Hemorrhage After Intravenous Thrombolysis Administration in an Acute Ischemic Stroke Patient with Chronic Pontine Microbleeds, a Case Report, Interdisciplinary Neurosurgery, 10.1016/j.inat.2020.100964, 23, (100964), Online publication date: 1-Mar-2021. Asai T, Ikezawa M, Oyama T, Ito S, Kimata M, Hoshinaga T, Ohta S, Ohno M, Susaki N, Kajita Y and Takahashi T (2021) Results of Mechanical Thrombectomy in Patients Aged ≥80 Years, Journal of Neuroendovascular Therapy, 10.5797/jnet.oa.2020-0029, 15:5, (323-331), . Koga M, Inoue M, Tanaka K, Satow T, Fukuda T, Ihara M, Itabashi R, Kudo K, Yamagami H and Toyoda K (2021) Cerebrovascular imaging to facilitate stroke reperfusion therapy in Japan急性期脳梗塞に対して適切な再灌流療法を促進するための画像診断, Rinsho Shinkeigaku, 10.5692/clinicalneurol.cn-001603, 61:8, (517-521), . Hawkes M and Rabinstein A (2020) Acute Ischemic Stroke Neurological Emergencies, 10.1007/978-3-030-28072-7_9, (171-188), . Mujer M, Rai M, Atti V, Dimaandal I, Chan A, Shrotriya S, Gundabolu K and Dhakal P (2020) An Update on the Reversal of Non-Vitamin K Antagonist Oral Anticoagulants, Advances in Hematology, 10.1155/2020/7636104, 2020, (1-10), Online publication date: 27-Jan-2020. Stachulski F (2020) Transitorische ischämische Attacke - Update 2020, CardioVasc, 10.1007/s15027-020-2159-z, 20:5, (33-37), Online publication date: 1-Oct-2020. Fernandes J (2021) Artificial Intelligence in Telemedicine Artificial Intelligence in Medicine, 10.1007/978-3-030-58080-3_93-1, (1-10), . EBIHARA K, TAJIMA Y, MATSUDA T, NISHINO W and HAYASAKA M (2020) Outcome of Mechanical Thrombectomy in Patients with Low Alberta Stroke Program Early Computed Tomography ScoresASPECTS低値の急性期血栓回収術の治療成績, Surgery for Cerebral Stroke, 10.2335/scs.48.200, 48:3, (200-204), . Drewry A (2020) How do I approach fever in the intensive care unit and should fever be treated? Evidence-Based Practice of Critical Care, 10.1016/B978-0-323-64068-8.00032-8, (161-168.e1), . Tsujimoto Y, Ikeda H, Otsuka R, Kawauchi T, Sano N, Hayase M and Toda H (2020) Two Patients Who Underwent Emergency Stenting for Iatrogenic Cervical Internal Carotid Artery Dissection during Thrombectomy, Journal of Neuroendovascular Therapy, 10.5797/jnet.cr.2019-0062, 14:6, (222-230), . Güneş M Demographic characteristics and recombinant tissue plasminogen activator treatment in patients with acute ischemic stroke, Ortadoğu Tıp Dergisi, 10.21601/ortadogutipdergisi.634446, 12:1, (78-83) Ospel J, Mayank A, Yoshimura S and Goyal M (2020) Optimizing Stroke Care for Patients with Large Vessel Occlusions: Current State of the Art and Future Directions, Journal of Neuroendovascular Therapy, 10.5797/jnet.ra.2020-0024, 14:6, (203-214), . Mishchenko T, Bokatuieva V and Mishchenko V (2020) Features of cognitive disorders in patients with cardioembolic stroke, Ukrains'kyi Visnyk Psykhonevrolohii, 10.36927/2079-0325-V28-is2-2020-3:Volume 28, issue 2 (103), (16-21), Online publication date: 20-Jul-2020. Pushko O and Lytvynenko N (2020) MODERN ASPECTS IN THE PARADIGM OF ACUTE HEMISPHERIC ISCHEMIC STROKE: FEATURES OF CLINICAL PRESENTATION, SCREENING, THERAPEUTIC AND NEURO-REHABILITATION PROSPECTS, Bulletin of Problems Biology and Medicine, 10.29254/2077-4214-2020-3-157-30-35, 3:1, (30), . Battaglini D, Robba C, Lopes da Silva A, dos Santos Samary C, Leme Silva P, Dal Pizzol F, Pelosi P and Rocco P (2020) Brain–heart interaction after acute ischemic stroke, Critical Care, 10.1186/s13054-020-02885-8, 24:1, Online publication date: 1-Dec-2020. Cavallari M, D'Ercole L, Klersy C, Sanfilippo G, Sgreccia A, Huasen B, Thyrion Zappoli F and Lafe E (2020) Typical values related to the complexity of interventional treatment of acute ischemic stroke, Physica Medica, 10.1016/j.ejmp.2020.09.016, 78, (129-136), Online publication date: 1-Oct-2020. Palaparti R, Palaparthi S, S Chowdary P, Koduru G, Maganti P, Kondru P, Ghanta S, Mannuva B and Yendapalli S (2020) Transesophageal echocardiography for aortic arch atheromas in patients with cryptogenic stroke/transient ischemic attack – An underutilized entity, Heart India, 10.4103/heartindia.heartindia_49_19, 8:2, (56), . Semenenko A, Kondratsky B, Hrebtiy G, Malyk S, Hinhuliak M, Bodnar R, Hinhuliak A and Zheliba L (2019) CORRECTION OF NEUROLOGICAL DEFICIENCY IN PATIENTS WITH ACUTE ISCHEMIC STROKE BY APPLICATION OF DIFFERENT QUALITATIVE COMPOSITION OF INFUSION SOLUTIONS, Wiadomości Lekarskie, 10.36740/WLek201904107, 72:4, (543-547), Online publication date: 1-Apr-2019. Lv S, Zhu D and Gu Q (2019) Clinical characteristics of and risk factors for gastrointestinal infection in patients with acute cerebral infarction, World Chinese Journal of Digestology, 10.11569/wcjd.v27.i11.682, 27:11, (682-687), Online publication date: 8-Jun-2019. Urbach H, Kellner E and Egger K (2019) Acute Stroke Imaging in the Era of the DAWN, DEFUSE 3 and WAKE-UP Study Findings, European Neurological Review, 10.17925/ENR.2019.14.1.24, 14:1, (24), . Wengrofsky P, Lee J and N. Makaryus A (2019) Dyslipidemia and Its Role in the Pathogenesis of Atherosclerotic Cardiovascular Disease: Implications for Evaluation and Targets for Treatment of Dyslipidemia Based on Recent Guidelines Dyslipidemia, 10.5772/intechopen.85772 Anita A and Zoran A (2019) Acute Ischemic or Hemorrhagic Stroke Syndromes Fungal Infections of the Central Nervous System, 10.1007/978-3-030-06088-6_26, (335-343), . Landínez Martínez D and Montoya Arenas D (2019) Políticas de salud pública para la prevención y el tratamiento de la enfermedad vascular cerebral: una revisión sistemática por medio de la metodología ToS (Tree of Science), Medicina UPB, 10.18566/medupb.v38n2.a05, 38:2, (129-139), . Martín F, Tarducci M, Tabares S, Martín J and Sembaj A (2019) Aplicación de los sistemas TOAST y CCS en el diagnóstico de accidente cerebrovascular isquémico, Neurología, Neurocirugía y Psiquiatría, 10.35366/NNP191E, 47:1, (22-28), . Aung K (2019) Guideline: Panel recommends maintaining SpO 2 at no higher than 96% in most acutely ill hospitalized patients , Annals of Internal Medicine, 10.7326/ACPJ201903190-026, 170:6, (JC26), Online publication date: 19-Mar-2019. Absher J (2019) Pooled RCTs: In acute ischemic stroke with salvageable brain tissue, alteplase at 4.5 to 9 hours improved function, Annals of Internal Medicine, 10.7326/ACPJ201910150-044, 171:8, (JC44), Online publication date: 15-Oct-2019. Li J, Liu J, Ma Y, Peng P, He X and Guo W (2019) Imbalanced Regional Development of Acute Ischemic Stroke Care in Emergency Departments in China, Emergency Medicine International, 10.1155/2019/3747910, 2019, (1-7), Online publication date: 6-Aug-2019. Brooks D and Schindler J (2019) Management of Hyperlipidemia After Stroke, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-019-0774-8, 21:12, Online publication date: 1-Dec-2019. Shi H, Wee C and John S (2019) Post-thrombolysis rupture of small lenticulostriate aneurysms: A report of 2 consecutive cases, Journal of Clinical Neuroscience, 10.1016/j.jocn.2018.10.087, 60, (148-150), Online publication date: 1-Feb-2019. Fedin A and Badalyan K (2019) Review of clinical guidelines for the treatment and prevention of ischemic stroke, Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova, 10.17116/jnevro201911908295, 119:8, (95), . Bohara M, Nishimuta Y, Sadamura Y, Kawahara D, Komasaku S, Mori M, Yamada M, Tokimura H and Yoshimoto K (2019) Continuous Educational Interventions Help Emergency Medical Services Effectively Reduce the Therapeutic Time in Acute Ischemic Stroke, Journal of Neuroendovascular Therapy, 10.5797/jnet.oa.2019-0073, 13:12, (481-486), . Frieden R (2018) In embolic stroke of undetermined source, rivaroxaban vs aspirin did not reduce recurrence and increased bleeding, Annals of Internal Medicine, 10.7326/ACPJC-2018-169-6-032, 169:6, (JC32), Online publication date: 18-Sep-2018. Lan L, Li X, Rong X, Zhang X, Wang H, Li Y, Li M, Shen Q and Peng Y Thrombolysis for Wake-Up Stroke Base on Neuroimaging a Meta-Analysis of Comparative Studies, SSRN Electronic Journal, 10.2139/ssrn.3214927 Kloner R, King K and Harrington M (2018) No-reflow phenomenon in the heart and brain, American Journal of Physiology-Heart and Circulatory Physiology, 10.1152/ajpheart.00183.2018, 315:3, (H550-H562), Online publication date: 1-Sep-2018. Kang H, Lee S, Heo S, Chang D and Kim B (2021) Clopidogrel Resistance in Patients With Stroke Recurrence Under Single or Dual Antiplatelet Treatment, Frontiers in Neurology, 10.3389/fneur.2021.652416, 12 Cabral L, Mont’Alverne F, Silva H, Passos Filho P, Magalhães P, Bianchin M and Nogueira R (2021) Device size selection can enhance Y-stentrieving efficacy and safety as a rescue strategy in stroke thrombectomy, Journal of NeuroInterventional Surgery, 10.1136/neurintsurg-2021-017751, (neurintsurg-2021-017751) Ali F, Hamid U, Zaidat O, Bhatti D and Kalia J (2020) Role of Artificial Intelligence in TeleStroke: An Overview, Frontiers in Neurology, 10.3389/fneur.2020.559322, 11 Zhou K, Cao Y, He X, Qiu Z, Liu S, Gong Z, Shuai J and Yang Q (2021) A Comparison of Safety and Effectiveness Between Wingspan and Neuroform Stents in Patients With Middle Cerebral Artery Stenosis, Frontiers in Neurology, 10.3389/fneur.2021.527541, 12 Kobalava Z, Konradi A, Nedogoda S, Shlyakhto E, Arutyunov G, Baranova E, Barbarash O, Boitsov S, Vavilova T, Villevalde S, Galyavich A, Glezer M, Grineva E, Grinstein Y, Drapkina O, Zhernakova Y, Zvartau N, Kislyak O, Koziolova N, Kosmacheva E, Kotovskaya Y, Libis R, Lopatin Y, Nebiridze D, Nedoshivin A, Ostroumova O, Oschepkova E, Ratova L, Skibitsky V, Tkacheva O, Chazova I, Chesnikova A, Chumakova G, Shalnova S, Shestakova M, Yakushin S and Yanishevsky S (2020) Arterial hypertension in adults. Clinical guidelines 2020, Russian Journal of Cardiology, 10.15829/1560-4071-2020-3-3786, 25:3, (3786) Stack C and Cole J (2021) The Clinical Approach to Stroke in Young Adults Stroke, 10.36255/exonpublications.stroke.adultstroke.2021, (53-78) Ciarambino T, Giannico O, Campanile A, Fischetti A, Barabgelata E, Ambrosino I, Para O, Politi C and Giordano M (2021) Gender differences in ischemic stroke intra-hospital mortality: a systematic review, Italian Journal of Medicine, 10.4081/itjm.2021.1378, 15:2 Shirokov E (2020) COVID-associated ischemic stroke, Clinical Medicine (Russian Journal), 10.30629/0023-2149-2020-98-5-375-377, 98:5, (375-377) Lawner B, Szabo K, Daly J, Foster K, McCoy P, Poliner D, Poremba M, Nawrocki P and Rahangdale R (2019) Challenges Related to the Implementation of an EMS-Administered, Large Vessel Occlusion Stroke Score, Western Journal of Emergency Medicine, 10.5811/westjem.2019.9.43127, 21:2, (441-448) Velkov V (2020) High sensitivity measurement of cardiac troponins: algorithms, interpretations, clinical consequences, Medical alphabet, 10.33667/2078-5631-2020-7-30-41:7, (30-41) Sun C, Li X, Zhao Z, Chen X, Huang C, Li X, Shan Y, Zou Y, Liu Y, Ibrahim M, Nyame L, Song B, Wang F, Zheng X, Hu J, Zhao Z, Zhou J and Zou J (2019) Safety and Efficacy of Tirofiban Combined With Mechanical Thrombectomy Depend on Ischemic Stroke Etiology, Frontiers in Neurology, 10.3389/fneur.2019.01100, 10 Kicherova O, Rejhert L and Ahmetianov M (2021) Risk factors for ischemic stroke. The role of vitamin D, Ural Medical Journal, 10.52420/2071-5943-2021-20-4-93-98, 20:4, (93-98) Kohli V and Koltz M (2021) Indications for Surgical Intervention in the Treatment of Ischemic Stroke Stroke, 10.36255/exonpublications.stroke.surgicalintervention.2021, (97-110) Yan X, Liu Z, Guo Z, Sun Y, Jin H, Sun X, Sun H and Yang Y (2020) Positive Influence of Stroke Health Manager on Risk Factors Control and Medication Adherence After Ischemic Stroke, Frontiers in Neurology, 10.3389/fneur.2020.00168, 11 Shi Z, Guo S, Pan J, Xu C, Geng Y and Zheng S (2021) Increased Postoperative Fasting Glucose Is Associated With Unfavorable Outcomes in Patients Treated With Mechanical Thrombectomy Treatment, Frontiers in Neurology, 10.3389/fneur.2021.668363, 12 Lieschke F, Zheng Y, Schaefer J, van Leyen K and Foerch C (2020) Measurement of Platelet Function in an Experimental Stroke Model With Aspirin and Clopidogrel Treatment, Frontiers in Neurology, 10.3389/fneur.2020.00085, 11 McGarry B and 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the Relationship between Silent Cerebral Lesions and Triglyceride/HDL-Cholesterol in Patients with First Stroke Attack, Düzce Tıp Fakültesi Dergisi, 10.18678/dtfd.737978 Shirokov E, Glatko V and Sapronenkova O (2021) Modern algorithms for the diagnosis and treatment of transient ischaemic attacks, Clinical Medicine (Russian Journal), 10.30629/0023-2149-2021-99-2-85-90, 99:2, (85-90) Wu X, Liu Y, Nie C, Kang Z, Wang Q, Sun D, Li H, Liu Y and Mei B (2020) Efficacy and Safety of Intravenous Thrombolysis on Acute Branch Atheromatous Disease: A Retrospective Case–Control Study, Frontiers in Neurology, 10.3389/fneur.2020.00581, 11 KOCATÜRK Ö and KOCATÜRK M (2021) Endovasküler Akut İskemik İnme Tedavisi: İlk 100 Vakanın Analizi, Harran Üniversitesi Tıp Fakültesi Dergisi, 10.35440/hutfd.803058, (82-87) Arakelyan M, Bockeria L, Vasilieva E, Golitsyn S, Golukhova E, Gorev M, Davtyan K, Drapkina O, Kropacheva E, Kuchinskaya E, Lajovich L, Mironov N, Mishina I, Panchenko E, Revishvili A, Rzayev F, Tatarsky B, Utsumueva M, Shakhmatova O, Shlevkov N, Shpektor A, Andreev D, Artyukhina E, Barbarash O, Galyavich A, Duplyakov D, Zenin S, Lebedev D, Mikhailov E, Novikova N, Popov S, Filatov A, Shlyakhto E and Shubik Y (2021) 2020 Clinical guidelines for Atrial fibrillation and atrial flutter, Russian Journal of Cardiology, 10.15829/1560-4071-2021-4594, 26:7, (4594) EREN F and YÜCEL K (2021) İskemik ve Hemorajik İnme Hastalarında Kan Lipid Parametrelerinin Karşılaştırılması ve Mortalite ile İlişkisi, Sakarya Medical Journal, 10.31832/smj.849225 Huseynov A, Haselmann V, Kittel M, Bertsch T, Alonso A, Neumaier M, Borggrefe M and Hoffmann U (2020) Lupus Antibody Mimicking Reduced Plasmatic Coagulation in a Patient With Atrial Fibrillation and Ischemic Stroke, Frontiers in Neurology, 10.3389/fneur.2020.00896, 11 Related articles2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke AssociationWilliam J. Powers, et al. Stroke. 2018;49:e46-e99 March 2018Vol 49, Issue 3 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/STR.0000000000000163PMID: 29483362 Originally publishedMarch 1, 2018 PDF download Advertisement

The Journal of Clinical Neuroscience would like to thank all those who have reviewed articles in 2013.

The Journal of Clinical Neuroscience would like to thank all those who have reviewed articles in 2013.

We’re on the Right Path…

as you know, the impact factor is an objective method for assessing the importance of a journal. lists of current impact factors appear at regular intervals, about half way through the year. We have got good news for all authors who published in our journal last year and wish to do so in the future: the 2012 impact Factor for the journal has just been released (thomson reuters Journal Citation reports 2012) and is 1.379. in 2011, the impact Factor was 1.091. We received the first impact factor for our journal 3 years ago and it has been continually increasing ever since. Clinical Neuroradiology (CNR) is listed in two subject categories. in the prestigious Clinical Neurology category led by lancet Neurology, CNR was ranked 138th out of 191 journals, thus placing it in the immediate vicinity of reputable journals like the Journal of Neuroimaging or the Journal of Clinical Neuroscience. of the 120 journals in the radiology, Nuclear Medicine and Medical imaging category, which was led by Human Brain Mapping, CNR was placed 74th and ranked above long-established journals such as Acta Radiologica. Compared to 2011, CNR has moved up the ranking in both categories, demonstrating that its importance relative to other journals has also increased. in the Clinical Neurology category, CNR climbed 16 places and in the radiology, Nuclear Medicine and Medical imaging category—it moved up by 15! these improvements demonstrate that the articles published in CNR are of value to the neuroradiology community and that the journal is held in increasingly high regard. this is of course primarily attributable to the quality of the submitted manuscripts and thus represents your achievement! We, the editorial board and the publishers, want to thank you for your support and hope that we can continue to reckon with it in the future. We also take this to be confirmation of the success of our concept for the journal and ensure you that we will continue doing all we can to take CNR even further. Clin Neuroradiol (2013) 23:173 DOI 10.1007/s00062-013-0244-8

History of the Asian Australasian Society of Neurological Surgeons from 1964 to 2012: A personal account

A steering committee of the Asian Australasian Society of Neurological Surgeons (AASNS) first met on 17 October, 1961, and between 29 and 31 October 1964, the First Congress was held in Canberra, Australia. A Constitution was accepted and Sir Ian (Douglas) Miller was elected as the first President. The Society was established “to facilitate personal association of neurosurgeons in the region” and to develop training programs and neurosurgical services. The progress of the Society meetings is best tracked through the four-yearly scientific meetings, of which 13 have now been held. The AASNS is now a continental body within the World Federation of Neurosurgical Societies (WFNS), established in Geneva, Switzerland. Two special milestones have included the establishment of the Journal of Clinical Neuroscience in 1993 and the launching of the Asian Australasian Travelling Fellowship in 1987. The current President of the AASNS is Professor Andrew H. Kaye from Melbourne, Australia, and the President-elect of the WFNS is Professor Yong-Kwang Tu from Taipei, Taiwan.

Commentary: Development and validation of the Asian Migraine Criteria (AMC)

Precise and manageable diagnostic criteria are vital for researchers and clinicians dealing with headache. The lack of clear and accessible markers of the biological distinctions between different types of headache means that criteria are determined by expert consensus. The International Classification of Headache Disorders (ICHD) criteria are the current benchmark and are evolving. They are effective for research as they exclude questionable cases from consideration, but in clinical practice they are used inconsistently by neurologists, and rarely by general practitioners, because of complexity. In this issue of the Journal of Clinical Neuroscience, Ghandehari et al. have proposed a new set of criteria, the Asian Migraine Criteria (AMC). These criteria perform well against the gold-standard ICHD, but are almost as complex. They do not have the simplicity of the ID Migraine tool. Nevertheless, they are welcome: any tool that general practitioners may be attracted to use that increases the accuracy of headache diagnosis is to be applauded.

Commentary: An evaluation of mechanisms underlying the influence of step cues on gait in Parkinson’s disease

As patients lose their physical independence, disturbances in gait are a leading cause for institutional care in Parkinson’s disease (PD). For many years, clinicians have acknowledged the role that external visual cues often have on improving gait in PD. In this issue of the Journal of Clinical Neuroscience, C.A. Lebold and Q.J. Almeida present data that dissects out the roles of focused attention and proprioceptive processing in the amelioration of gait deficits. Their findings suggest that focused visual attention on the lower limbs in PD may be compensating for a deficit in proprioceptive processing. This study highlights the potential therapeutic benefits of strategies that could tap into this mechanism.

Commentary: Paraclinoid carotid aneurysms

Javalkar et al.,1 in this issue of the Journal of Clinical Neuroscience, have provided an excellent analysis of the current thinking regarding management of paraclinoid aneurysms and ophthalmic aneurysms, by both endovascular and surgical techniques. However, this comprehensive analysis and classification, in my view, overcomplicates the treatment of these aneurysms and may create fear that these aneurysms are of such complexity that they should be always considered first for endovascular repair.

Commentary: The past, present and future of imaging in multiple sclerosis

The review by Ramli et al. in a recent issue of the Journal of Clinical Neuroscience provides a short general overview of the past, present and future of imaging in multiple sclerosis (MS).1 The nature of such a review is by no means exhaustive, but rather helps give an insight into ongoing developments in MS imaging. The article will be of interest to individuals involved in the clinical management MS patients, as well as individuals interested in pursuing MS-related research.

Commentary: Huntington disease in a nonagenarian mistakenly diagnosed as normal pressure hydrocephalus

Huntington disease in the very elderly patient described by Dennhardt and LeDoux in this issue of the Journal of Clinical Neuroscience ( J Clin Neurosci 2010;17:1066–67) may have been unrecognised before diagnostic genetic testing. Huntington disease in this age group poses significant counselling challenges as some members of up to four generations may have inherited the mutation. In late onset patients gait disorder rather than chorea may be the most prominent feature at presentation. The range of phenotypic variation is evolving.

From Cavern-Dwellers to Cavernoma Science

HomeStrokeVol. 39, No. 12From Cavern-Dwellers to Cavernoma Science Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBFrom Cavern-Dwellers to Cavernoma ScienceTowards a New Philosophy of Cerebral Cavernous Malformations Christian Stapf and Dominique Hervé Christian StapfChristian Stapf From the “Centre de Référence des maladies Vasculaires rares du Cerveau et de l'Œil” (French Reference Center of Rare Vascular Diseases of the Brain and Eye, CERVCO), Department of Neurology, Hôpital Lariboisière, APHP, Paris, France. Search for more papers by this author and Dominique HervéDominique Hervé From the “Centre de Référence des maladies Vasculaires rares du Cerveau et de l'Œil” (French Reference Center of Rare Vascular Diseases of the Brain and Eye, CERVCO), Department of Neurology, Hôpital Lariboisière, APHP, Paris, France. Search for more papers by this author Originally published30 Oct 2008https://doi.org/10.1161/STROKEAHA.108.520783Stroke. 2008;39:3129–3130Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 30, 2008: Previous Version 1 See related article, pages 3222–3230.Since the introduction of noninvasive imaging tools roughly 30 years ago, vascular malformations of the brain have attracted increasing interest. Among them, cerebral cavernous malformations (CCM) appear to be the most frequently diagnosed entity with current prevalence estimates ranging from 100 to 500 cases per 100000 in the general population.1 They may come to clinical attention after epileptic seizures, progressive neurological syndromes, or symptomatic hemorrhage, but overall, asymptomatic lesions seem to be most frequently encountered since the introduction of highly sensitive gradient echo (T2*) weighted sequences in routine MR imaging protocols.2Despite increasing detection rates and growing insight into underlying molecular and genetic mechanisms, many practical issues remain as yet unsolved, particularly when it comes to actual patient care and counseling:First, no standardized imaging protocols exist. Brain MRI with the aforementioned T2*-weighted images are now considered the diagnostic standard, but the absence of contrast-enhanced T1 sequences may miss an associated developmental venous anomaly and vice versa, which may for example impact on the strategy of any neurosurgical intervention (Figure 1). Download figureDownload PowerPointFigure 1. Brain MRI study of a 37-year-old woman presenting with left internuclear ophtalmoplegia, ataxia, and a dissociated sensory deficit attributable to a left posterior pontine hematoma on FLAIR-weighted images (left plane). Three-month follow-up MRI shows a pontine developmental venous anomaly (DVA; gadolinium-enhanced T1, middle plane). Only the gradient echo sequence (T2*, right plane) reveals a cavernous malformation at the inferior left ponto-peduncular junction. The cavernoma, not the DVA, constitutes the actual bleeding source.Also, no treatment standards for specific CCM interventions are readily available. If indicated, neurosurgical excision is the treatment of choice as stereotactic radiotherapy appears to have less favorable results.34 Therapeutic decisions are ideally based on a multidisciplinary discussion considering cavernoma characteristics (such as size, location, bleeding status, etc) and the patient’s overall profile (including age, neurological symptoms, family history, etc). However, no controlled clinical data exist so far to guide treatment strategies based on prospective natural history versus surgical outcome predictions.Most important, the long-term bleeding risk has been insufficiently studied. Recent estimates from familial (ie, multiple CCM) cases suggest crude spontaneous hemorrhage rates may be as low as 0.6% per year and lesion,5 but the potential risk of otherwise indicated antiplatelet treatment and oral anticoagulation is currently unclear (Figure 2), and the impact of pregnancies and hormonal treatment remains highly controversial. Download figureDownload PowerPointFigure 2. A not so uncommon dilemma: is oral anticoagulation safe in patients with asymptomatic CCM? In this example, MR imaging shows an acute ischemic lesion on DWI (left plane) suggesting embolism into a distal MCA branch. The 58-year-old patient has a history of arterial hypertension and was found to have atrial fibrillation as the most likely cause of the stroke. Gradient echo sequences reveal an incidentally discovered, asymptomatic cavernous malformation in the right posterior frontal white matter (right plane). No data exist on whether the patient’s long-term benefit will be higher with or without oral anticoagulation.The culmination of these continuing clinical dilemmas is that the literature does not even provide a consistent definition of what CCM hemorrhage actually is. Quite commonly, available case series lump together symptomatic and asymptomatic bleeding, intracavernous and extralesional hemorrhage extension, acute bleeding and “chronic” hemosiderin, etc, to name but a few categories.In this confusing situation, the Angioma Alliance and its scientific advisory board should be congratulated for their welcome initiative to develop a consensus proposal for CCM reporting standards as published in the current issue of Stroke.6 Based on an extensive literature review, Al-Shahi Salman and coauthors develop a publication-based, clinical definition of CCM hemorrhage and offer pragmatic recommendations for CCM reporting terminology in clinical practice and future research protocols.Scientific consensus in the medical community is often achieved through authorative agreement among a panel of established contributors. Sometimes, writing groups may simply agree on already-existing practice, as has been the case for the proposed standards defining reporting terminology for AVM research.78 More often, however, the path to agreement among specialists is more complex, as evidence from appropriately designed studies, but also common experience, overlapping strategies, etc may serve as a basis for final editing of appropriate consensus statements. Some recommendations may eventually have legal implications, define current standards of care, and inspire the content of continued medical education programs and future curricula of academic medical schools. The methodological downside of “authorative” consensus is that its content may be susceptible to extrascientific interests, political considerations, and personal ambitions of individual panel members or groups.By comparison, Al-Shahi Salman at al chose a different, almost “democratic,” approach: Based on a systematic literature review with transparent, up-to-date methodology, the authors develop a publication-based definition of CCM hemorrhage along with consensus recommendations for reporting variables in CCM clinical research. Whether defining consensus via an arithmetic majority of published sources is appropriate or not may be subject to future methodological discussions—the validity of a given hypothesis may not correlate with the number of reports or cited references. In the end, the principle of majority remains an appropriate (if not the most appropriate) tool for political decision-making, but it does not necessarily lead to what may be called scientific truth.These theoretical considerations aside, the major advantage of the new CCM reporting standards is not only the filling of an important gap. Moreover (and different from the widespread temptation of premature conclusions), they are but the starting point to future research and remain open to further testing in prospective studies. Jerzy Neyman, the mathematician to whom we owe the concept of confidence intervals, comes to mind as he wrote: “Not all the revolutionary developments in science or technology are initiated by the identification and rejection of a dogmatic assumption so that not all such developments are Copernican in character. Occasionally it happens that, through apparently minor contributions of many scholars, all the pieces of a complicated jigsaw puzzle are accumulated but no comprehensive overall picture is available.”9 Thanks to the initiative of the Angioma Alliance, the pieces in the jigsaw puzzle of clinical CCM research will eventually have a standardized size, and future contributors will finally speak the same language.The opinions in this editorial are not necessarily those of the editors or of the American Heart Association.Sources of FundingCERVCO is supported by public funds by the French Ministry of Health.DisclosuresNone.FootnotesCorrespondence to Christian Stapf, MD, Department of Neurology, Hôpital Laribosière (APHP), 2, Rue Ambroise Paré, 75475 Paris cedex 10, France. E-mail [email protected] References 1 Labauge P, Denier C, Bergametti F, Tournier-Lasserve E. Lancet Neurology. 2007; 6: 237–244.CrossrefMedlineGoogle Scholar2 Lehnhardt FG, von Smekal U, Rückriem B, Stenzel W, Neveling M, Heiss WD, Jacobs AH. Value of gradient-echo magnetic resonance imaging in the diagnosis of familial cerebral cavernous malformation. Arch Neurol. 2005; 62: 653–658.CrossrefMedlineGoogle Scholar3 Mathiesen T, Edner G, Kihlström L. Deep and brainstem cavernomas : a consecutive 8-year series. J Neurosurgery. 2003; 99: 31–37.CrossrefMedlineGoogle Scholar4 Pollock BE, Garces YI, Stafford SL, Foote RL, Schomberg PJ, Link MJ. Stereotactic radiosurgery for cavernous malformations. J Neurosurg. 2000; 93: 987–991.CrossrefMedlineGoogle Scholar5 Labauge P, Brunerau L, Laberge S, Houtteville JP. Prospective follow-up of 33 asymptomatic patients with familial cerebral cavernous malformations. Neurology. 2001; 57: 1825–1828.CrossrefMedlineGoogle Scholar6 Al-Shahi Salman R, Berg MJ, Morrison L, Awad IA. Hemorrhage from cavernous malformations of the brain: definition and reporting standards. Stroke. 2008; 40: 3222–3230.Google Scholar7 Stapf C, Mast H, Sciacca RR, Berenstein A, Nelson PK, Gobin YP, Pile-Spellman J, Mohr JP, for the New York Islands Study Collaborators. The New York Islands AVM Study: Design, study progress, and initial results. Stroke. 2003; 34: e29–33.LinkGoogle Scholar8 Joint writing group of technology assessment comittee et al. Reporting terminology for brain arteriovenous malformation clinical and radiographic features for use in clinical trials. Stroke. 2001; 32: 1430–1442.CrossrefMedlineGoogle Scholar9 Neyman J. The Heritage of Copernicus: Theories “Pleasing to the Mind”. The MIT Press; Cambridge, MA 1974.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Gomez-Paz S, Salem M, Maragkos G, Ascanio L, Enriquez-Marulanda A, Lee M, Kicielinski K, Moore J, Thomas A and Ogilvy C (2020) Role of aspirin and statin therapy in patients with cerebral cavernous malformations, Journal of Clinical Neuroscience, 10.1016/j.jocn.2020.04.012, 78, (246-251), Online publication date: 1-Aug-2020. Akalan N (2020) Cavernomas in Children Cavernomas of the CNS, 10.1007/978-3-030-49406-3_12, (191-209), . Hacein-Bey L, Varelas P, Ulmer J, Mark L, Raghavan K and Provenzale J (2016) Imaging of Cerebrovascular Disease in Pregnancy and the Puerperium, American Journal of Roentgenology, 10.2214/AJR.15.15059, 206:1, (26-38), Online publication date: 1-Jan-2016. Marx P (2014) Fahreignungsbeurteilung bei HirndurchblutungsstörungenDriving ability with cerebral perfusion disorders, Der Nervenarzt, 10.1007/s00115-014-4010-1, 85:7, (835-840), Online publication date: 1-Jul-2014. Schneble H, Soumare A, Hervé D, Bresson D, Guichard J, Riant F, Tournier-Lasserve E, Tzourio C, Chabriat H and Stapf C (2012) Antithrombotic Therapy and Bleeding Risk in a Prospective Cohort Study of Patients With Cerebral Cavernous Malformations, Stroke, 43:12, (3196-3199), Online publication date: 1-Dec-2012. Flemming K (2012) Predicting the clinical behaviour of cavernous malformations, The Lancet Neurology, 10.1016/S1474-4422(12)70016-9, 11:3, (202-203), Online publication date: 1-Mar-2012. Berg M and Vay T (2011) Clinical features and medical management of cavernous malformations Cavernous Malformations of the Nervous System, 10.1017/CBO9781139003636.009, (65-78) (2011) Clinical features, imaging and diagnostic work-up Cavernous Malformations of the Nervous System, 10.1017/CBO9781139003636.008, (49-102) Pistoia F, Ferri C, Desideri G, Rosano G and Sarà M (2010) In uno omnia: Anti-thrombotic agents in challenging comorbidities, Brain Injury, 10.3109/02699051003709573, 24:5, (792-796), Online publication date: 1-May-2010. December 2008Vol 39, Issue 12 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.108.520783PMID: 18974378 Originally publishedOctober 30, 2008 Keywordsstrokeintracerebral hemorrhagecerebral cavernous malformationclinical trialsPDF download Advertisement

439: Detection of large-scale deletions in mitochondrial DNA using DNA extracted from salivary samples

s / Journal of Clinical Neuroscience 15 (2008) 337–369 355 Results: Two of 35 (6%) patients had peri-operative strokes. Sixteen of 32 (50%) with post-operative imaging had new ischemic lesions including 5 of 6 with combined cardiac valve and CABG surgery. There were a range of 1–17 lesions, each <1 cm diameter except in 3 patients with large confluent areas of ischemia. Twenty of 29 (69%) patients with post-operative testing had significant cognitive declines in at least one domain (range 1–4), including all those with new ischemic lesions (p = 0.005). Conclusion: Brain injury is common following cardiac valve surgery: 6% have new neurological deficit and just over two thirds have measurable cognitive decline. Half of the patients had new post-operative ischemic lesions on DWI and these appeared embolic in nature. To our knowledge, this is the first study to link cognitive decline and cerebral ischemia. Cardiac surgery may be a useful model of human stroke in late phase IIB trials of putative neuroprotective therapies. doi:10.1016/j.jocn.2007.07.049 439: Detection of large-scale deletions in mitochondrial DNA using DNA extracted from salivary samples Himesha Vandebona , Con Yiannikas , Carolyn M. Sue ; Department of Neurogenetics, Kolling Institute of Medical Research, University of Sydney, Royal North Shore Hospital, Australia; Department of Neurology, Concord

Global Hemispheric CT Hypoperfusion May Differentiate Headache With Associated Neurological Deficits and Lymphocytosis From Acute Stroke

HomeStrokeVol. 39, No. 2Global Hemispheric CT Hypoperfusion May Differentiate Headache With Associated Neurological Deficits and Lymphocytosis From Acute Stroke Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBGlobal Hemispheric CT Hypoperfusion May Differentiate Headache With Associated Neurological Deficits and Lymphocytosis From Acute Stroke Jacqueline A. Pettersen, MD, MSc, FRCPC, Richard I. Aviv, MBChB, FRCR(UK), Sandra E. Black, MD, FRCPC, Allan J. Fox, MD, FRCPC, Andrew Lim, MD and Brian J. Murray, MD, FRCPC Jacqueline A. PettersenJacqueline A. Pettersen From the LC Campbell Cognitive Neurology Research Unit and Heart and Stroke Foundation Centre for Stroke Recovery (J.A.P., S.E.B.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; the Neuroscience Research Program (J.A.P., R.I.A., S.E.B., A.J.F., B.J.M.), Sunnybrook Research Institute, Toronto, Ontario, Canada; and the Division of Neurology, Department of Medicine (J.A.P., S.E.B., A.L., B.J.M.) and Department of Medical Imaging (R.I.A., A.J.F.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Search for more papers by this author , Richard I. AvivRichard I. Aviv From the LC Campbell Cognitive Neurology Research Unit and Heart and Stroke Foundation Centre for Stroke Recovery (J.A.P., S.E.B.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; the Neuroscience Research Program (J.A.P., R.I.A., S.E.B., A.J.F., B.J.M.), Sunnybrook Research Institute, Toronto, Ontario, Canada; and the Division of Neurology, Department of Medicine (J.A.P., S.E.B., A.L., B.J.M.) and Department of Medical Imaging (R.I.A., A.J.F.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Search for more papers by this author , Sandra E. BlackSandra E. Black From the LC Campbell Cognitive Neurology Research Unit and Heart and Stroke Foundation Centre for Stroke Recovery (J.A.P., S.E.B.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; the Neuroscience Research Program (J.A.P., R.I.A., S.E.B., A.J.F., B.J.M.), Sunnybrook Research Institute, Toronto, Ontario, Canada; and the Division of Neurology, Department of Medicine (J.A.P., S.E.B., A.L., B.J.M.) and Department of Medical Imaging (R.I.A., A.J.F.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Search for more papers by this author , Allan J. FoxAllan J. Fox From the LC Campbell Cognitive Neurology Research Unit and Heart and Stroke Foundation Centre for Stroke Recovery (J.A.P., S.E.B.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; the Neuroscience Research Program (J.A.P., R.I.A., S.E.B., A.J.F., B.J.M.), Sunnybrook Research Institute, Toronto, Ontario, Canada; and the Division of Neurology, Department of Medicine (J.A.P., S.E.B., A.L., B.J.M.) and Department of Medical Imaging (R.I.A., A.J.F.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Search for more papers by this author , Andrew LimAndrew Lim From the LC Campbell Cognitive Neurology Research Unit and Heart and Stroke Foundation Centre for Stroke Recovery (J.A.P., S.E.B.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; the Neuroscience Research Program (J.A.P., R.I.A., S.E.B., A.J.F., B.J.M.), Sunnybrook Research Institute, Toronto, Ontario, Canada; and the Division of Neurology, Department of Medicine (J.A.P., S.E.B., A.L., B.J.M.) and Department of Medical Imaging (R.I.A., A.J.F.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Search for more papers by this author and Brian J. MurrayBrian J. Murray From the LC Campbell Cognitive Neurology Research Unit and Heart and Stroke Foundation Centre for Stroke Recovery (J.A.P., S.E.B.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; the Neuroscience Research Program (J.A.P., R.I.A., S.E.B., A.J.F., B.J.M.), Sunnybrook Research Institute, Toronto, Ontario, Canada; and the Division of Neurology, Department of Medicine (J.A.P., S.E.B., A.L., B.J.M.) and Department of Medical Imaging (R.I.A., A.J.F.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Search for more papers by this author Originally published3 Jan 2008https://doi.org/10.1161/STROKEAHA.107.493791Stroke. 2008;39:492–493Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 3, 2008: Previous Version 1 Headache with associated neurological deficits and lymphocytosis (HaNDL) is characterized by temporary recurrent neurological deficits, moderate–severe headache, cerebrospinal fluid lymphocytosis, elevated protein, and increased opening pressure.1 Although CT and MRI should be normal, single photon emission CT may indicate focal hypoperfusion and electroencephalogram may reveal slowing or even epileptiform activity2 resolving once the patient is symptom-free (3 months). Catheter angiography also yields normal results but may trigger an acute neurological episode.3,4Because HaNDL is a benign, self-limited syndrome, it is important to differentiate it from cerebrovascular disease to avoid unnecessary interventions such as catheter angiography and thrombolysis. We present a case initially thought to be acute stroke in which the patient was considered for thrombolysis. CT perfusion changes atypical for stroke made stroke diagnosis questionable and thrombolysis was withheld.Case ReportA 31-year-old man with hypertension, dyslipidemia, and sleep apnea (treated with continuous positive airway pressure), but no history of prior migraine, was brought into our emergency department by ambulance with suspected acute ischemic stroke. He had become aphasic at work so his coworkers called 911. On examination, he was globally aphasic without focal weakness or obvious sensory changes aside from questionable mild right facial paresis (National Institutes of Health Stroke Scale score 6). A noncontrast CT and CT angiogram (CTA) were normal, but CT perfusion revealed a striking pattern of decreased and delayed perfusion to the entire left hemisphere (Figure A). Compared with the right hemisphere, there was a reduction in cerebral blood flow and volume to 80% and 95%, respectively, and the mean transit time was prolonged to 136%, all consistent with a pattern of benign oligemia rather than ischemia.5 Given these findings, he was not offered thrombolysis. Over the subsequent hour, his aphasia began to improve and he reported an evolving severe headache that was alleviated by acetaminophen. By 8 hours postonset, his symptoms had resolved. He experienced a second episode of global aphasia the next day accompanied by right arm paresthesias, which was followed by a severe, albeit gradual-onset, bilateral throbbing headache lasting for several hours. A third episode occurred while the patient was on a day pass 2 days later. He developed a recurrent severe headache with associated nausea/vomiting and concomitant confusion (he ran away from the ambulance attendants) that resolved within 12 hours while back in the hospital. Download figureDownload PowerPointFigure. Axial images reveal (A) prolonged CT mean transit time to the entire left hemisphere relative to the right at presentation (red denotes prolongation); (B) normal MRI fluid-attenuated inversion recovery performed 3 days after the acute event; and (C) normal and symmetric CT mean transit time 6 months postonset.Routine blood work, toxicology, and MRI, including diffusion-weighted imaging, MR angiography, and fluid-attenuated inversion recovery (Figure B), were normal. A lumbar puncture revealed elevated opening pressure of 270 mm H20, increased protein (834 mg/L), and pleocytosis (447×106/mL) with 96% lymphocytes. Glucose and Gram’s stain/culture were normal as was a complete viral workup, including herpes simplex, West Nile, cytomegalovirus, syphilis, and HIV. An electroencephalogram revealed intermittent delta wave slowing and transient sharp waves in the left temporal lobe.The patient was discharged on carbamazepine as a precaution for possible seizures. He had no further neurological episodes or headaches and returned to work. Repeat clinical examination, CT perfusion (see Figure C), electroencephalogram, and formal detailed neuropsychological testing all performed 4 to 7 months later were within normal limits. The carbamazepine was tapered and he remains symptom-free. A final diagnosis of HaNDL was given because his presentation met the diagnostic criteria in the absence of a more likely diagnosis.DiscussionIt is important for neurologists to be aware of HaNDL syndrome. The presentation of sudden-onset neurological deficits illustrates the clinical similarities between HaNDL and acute stroke. A plain CT may be unremarkable in both conditions. However, CT perfusion in acute stroke should reveal significant reductions in cerebral blood flow and possibly cerebral blood volume with a prolongation of mean transit time in an arterial territory. Ischemia of 3 vascular territories is unusual, but theoretically may be produced where an occluded proximal internal carotid artery supplies a fetal-type posterior communicating artery in the absence of an anterior communicating artery. Such an arrangement was excluded by CT angiography as was any vascular occlusion. Furthermore, hemiparesis would be expected with this distribution of ischemia. We speculate that our patient did not experience hemiparesis with such a large affected distribution because the degree of perfusion impairment (ie, oligemia rather than ischemia) may not have reached a unique threshold sufficient to impair motor function. Furthermore, cortical spreading depression may affect a more focal area of the brain reflected by the temporal lobe changes seen on electroencephalogram despite a larger distribution of oligemia that was observed on perfusion imaging. This may explain why language, and not motor function, was impaired in this case.Our findings corroborate those of Fuentes and colleagues2 who demonstrated globally reduced left hemispheric uptake on single photon emission CT during acute aphasia in a HaNDL case. Other reports describing more focal single photon emission CT changes after the acute event3 may have captured resolving perfusion deficits. Transcranial Doppler performed postevent in HaNDL has revealed decreased flow velocities in the ipsilateral middle cerebral artery.6 Taken together, the changes in blood flow and associated electroencephalogram activity further supports the hypothesis that a HaNDL neurological attack may represent a cortical spreading wave of depression with associated oligemia,2 presumed to be due to a viral or postviral etiology.3 Interestingly, perfusion is similarly decreased in migraine aura, although only within the occipital lobe.7To our knowledge, this is the first report of global hemispheric CT perfusion changes during an acute neurological attack of HaNDL. Given the benign, self-limited nature of this syndrome, such a finding in the absence of vascular occlusion may differentiate it from acute stroke avoiding unnecessary interventions. Compared with single photon emission CT, CT perfusion is a more accessible, available, and rapid form of blood flow assessment with less radiation exposure.8 We chose CT perfusion for the investigation of this case because it is routinely used at our center for the evaluation of suspected acute stroke due to its rapid acquisition and processing characteristics. However, it is likely that MR perfusion would have yielded similar hemispheric hypoperfusion findings. We conclude that CT perfusion may help differentiate stroke from the more benign HaNDL syndrome in the acute setting.We thank the patient for agreeing to share details of his clinical assessment. He provided signed informed consent.Sources of FundingJ.A.P. received fellowship funding through the Canadian Institute of Health Research (CIHR) and the Alberta Heritage Foundation of Medical Research (AHFMR).DisclosuresNone.FootnotesCorrespondence to Jacqueline A. Pettersen, MD, MSc, FRCPC, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, A421-2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5. E-mail [email protected] References 1 Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004; 24 (suppl 1): 9–160.CrossrefMedlineGoogle Scholar2 Fuentes B, Diez Tejedor E, Pascual J, Coya J, Quirce R. Cerebral blood flow changes in pseudomigraine with pleocytosis analyzed by single photon emission computed tomography. A spreading depression mechanism? Cephalalgia. 1998; 18: 570–573;discussion 531.CrossrefMedlineGoogle Scholar3 Gomez-Aranda F, Canadillas F, Marti-Masso JF, Diez-Tejedor E, Serrano PJ, Leira R, Gracia M, Pascual J. Pseudomigraine with temporary neurological symptoms and lymphocytic pleocytosis. A report of 50 cases. Brain. 1997; 120: 1105–1113.CrossrefMedlineGoogle Scholar4 Toth CC. Persistent cerebrospinal fluid abnormalities in the syndrome of headache, neurological deficit, and cerebrospinal fluid lymphocytosis despite resolution of clinical symptomatology. Headache. 2002; 42: 1038–1043.CrossrefMedlineGoogle Scholar5 Schaefer PW, Roccatagliata L, Ledezma C, Hoh B, Schwamm LH, Koroshetz W. First-pass quantitative CT perfusion identifies thresholds for salvageable penumbra in acute stroke patients treated with intra-arterial therapy. Am J Neuroradiol. 2006; 27: 20–25.MedlineGoogle Scholar6 Kappler J, Mohr S, Steinmetz H. Cerebral vasomotor changes in the transient syndrome of headache with neurologic deficits and CSF lymphocytosis (HaNDL). Headache. 1997; 37: 516–518.CrossrefMedlineGoogle Scholar7 Cutrer M, Sorensen GA, Weisskoff RM, Ostergaard L, Sanchez del Rio M, Lee EJ, Rosen BR, Moskovitz MA. Perfusion-weighted imaging defects during spontaneous migrainous aura. Ann Neurol. 1998; 43: 25–31.CrossrefMedlineGoogle Scholar8 Cohnen M, Wittsack HJ, Assadi S, Muskalla K, Ringelstein A, Poll LW, Saleh A, Modder U. Radiation exposure of patients in comprehensive computed tomography of the head in acute stroke. Am J Neuroradiol. 2006; 27: 1741–1745.MedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Bhat A, Mahajan V and Wolfe N (2021) Implicit bias in stroke care: A recurring old problem in the rising incidence of young stroke, Journal of Clinical Neuroscience, 10.1016/j.jocn.2020.12.017, 85, (27-35), Online publication date: 1-Mar-2021. Gago-Veiga A, Díaz de Terán J, González-García N, González-Oria C, González-Quintanilla V, Minguez-Olaondo A, Santos-Lasaosa S, Viguera Romero J and Pozo-Rosich P (2020) Cómo y cuándo derivar un paciente con cefalea secundaria y otros tipos de dolores craneofaciales desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología, Neurología, 10.1016/j.nrl.2017.08.002, 35:5, (323-331), Online publication date: 1-Jun-2020. Zhu K, Born D and Dilli E (2020) Secondary Headache: Current Update, Headache: The Journal of Head and Face Pain, 10.1111/head.13986, 60:10, (2654-2664), Online publication date: 1-Nov-2020. Gago-Veiga A, Díaz de Terán J, González-García N, González-Oria C, González-Quintanilla V, Minguez-Olaondo A, Santos-Lasaosa S, Viguera Romero J and Pozo-Rosich P (2020) How and when to refer patients diagnosed with secondary headache and other craniofacial pain in the emergency department and primary care: Recommendations of the Spanish Society of Neurology's Headache Study Group, Neurología (English Edition), 10.1016/j.nrleng.2017.08.003, 35:5, (323-331), Online publication date: 1-Jun-2020. Moulin S and Leys D (2019) Stroke mimics and chameleons, Current Opinion in Neurology, 10.1097/WCO.0000000000000620, 32:1, (54-59), Online publication date: 1-Feb-2019. Rodríguez-López C, Garzo Caldas N, Uriarte Pérez de Urabayen D, Sánchez Tornero M, Hilario Barrio A, Saiz Díaz R and González de la Aleja J (2019) A new MR radiological sign in HaNDL syndrome. A case report, Journal of Clinical Neuroscience, 10.1016/j.jocn.2018.11.018, 61, (274-276), Online publication date: 1-Mar-2019. 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