Subtle Signs Research Articles

Imaging Diagnosis and Management of Carpal Trauma and Instability-An Illustrated Guide.

Understanding the subtle signs of carpal instability and other unique injury patterns in the wrist is a critical skill for radiologists. Proper patient management and outcomes are directly dependent on the accurate interpretation of wrist imaging studies. This review will provide a detailed overview of typical imaging features of carpal trauma and instability, management, and complications, using multimodality imaging and original medical illustrations. A detailed overview of the osseous, ligamentous, arterial anatomy of the wrist, arcs of Gilula, and zones of vulnerability will be provided. Carpal fractures, dislocations, special radiographic views, and imaging pearls will be discussed. Instability patterns and the myriad of associate abbreviations (CID, CIND, CIC, CIA, VISI, DISI, SLD, LTD, MCI, SLAC, SNAC) will be clarified. Expected outcomes, potential complications, and management will be reviewed.

Utility of Hematological Parameters in Early Diagnosis of Neonatal Sepsis in Comparison to C-Reactive Protein

Abstract Background Neonatal sepsis is the most common cause of neonatal mortality and morbidity. As neonatal sepsis presents with subtle symptoms and signs, decision to start empirical antibiotics is most often based on risk profile. Hematological parameters and C-reactive protein (CRP) are routinely done as a part of sepsis screening, but isolation of microorganism on blood culture is the gold standard for diagnosis of sepsis. Methodology One-hundred neonates with suspected sepsis were studied and their hematological parameters, hematological scoring system (HSS), and CRP were correlated to blood culture. Results Among the study population, immature to total neutrophil count (I:T) ratio had the best sensitivity (94.1%) and negative predictive value (83.3%), followed by HSS with a sensitivity of 64.7% and negative predictive value of 68.4%, whereas CRP was more specific (75.9%). Conclusion HSS and CRP are good predictors of diagnosis of neonatal sepsis. I:T ratio had the best sensitivity and negative predictive value.

Biliary complications after liver transplantation: A computed tomography and magnetic resonance imaging pictorial review.

Biliary complications are the most common complications after liver transplantation. Computed tomography (CT) and magnetic resonance imaging (MRI) are cornerstones for timely diagnosis of biliary complications after liver transplantation. The diagnosis of these complications by CT and MRI requires expertise, mainly with respect to identifying subtle early signs to avoid missed or incorrect diagnoses. For example, biliary strictures may be misdiagnosed on MRI due to size mismatch of the common ducts of the donor and recipient, postoperative edema, pneumobilia, or susceptibility artifacts caused by surgical clips. Proper and prompt diagnosis of biliary complications after transplantation allows the timely initiation of appropriate management. The aim of this pictorial review is to illustrate various CT and MRI findings related to biliary complications after liver transplantation, based on time of presentation after surgery and frequency of occurrence.

Spinocerebellar Ataxia type 17 presenting with progressive myoclonic epilepsy.

•SCA17 should be included in the differential diagnoses of PMEs.•SCA17 is characterized by cerebellar features, myoclonic epilepsy, cognitive decline, psychiatric features, and chorea.•Subtle clinical signs like chorea can provide additional diagnostic clues to SCA17(HDL4), a Huntington disease phenocopy.

Dual tasking paradigm in clinical stages of early Alzheimer’s disease

AbstractBackgroundIn Alzheimer’s disease (AD) both motor and cognitive domains are impaired [1‐2]. However, these domains are usually assessed independently, even when performing dual‐task (DT) paradigms, the cognitive‐motor interaction (CMI) is not taken into account which may lead to misinterpretation of the patient’s global state. To date, there are no precise markers to neither detect subtle signs of pre‐clinical neurodegeneration nor accurately monitor disease progression.MethodWe have evaluated the motor and cognitive components of a DT paradigm concurrently (Figure 1). 50 participants, aged 60 to 80 years, were included in the study, distributed across four cohorts corresponding to progressive clinical stages of early AD [3]: 1) amyloid negative, cognitively healthy participants (control group), 2) amyloid positive pre‐symptomatic AD, 3) Mild Cognitive Impairment (MCI) due to AD and 4) mild AD. Two inertial measurement units (IMUs) (Physilog, GaitUp S.A.) were attached to each foot to measure gait parameters and a small microphone (Wireless GO, RØDE) was attached to the shirt to record counting. Both timing and gait features were extracted from raw data, however only conventional features, correct response rate (CRR) and gait speed, were considered for this abstract and were used to evaluate the CMI based on Plummer’s classification system [5]. Moreover two‐way ANOVA was carried out to evaluate the effect of cohort and cognitive load conditions on the CMI.ResultOur results show that there is a significant drop in performance at both the cognitive and motor tasks while performing DT and that this drop is more pronounced as we move toward stages of greater cognitive impairment and as we increase the cognitive load of the task (Figure 2). Moreover, CMI shows a cognitive‐priority trade‐off in all cohorts (better/similar counting while slower walking), but movement toward mutual interference effect (worst counting and slower walking) when increasing cognitive load and state of cognitive decline (Figure 3).ConclusionTo our knowledge, this is the first feasibility study assessing the CMI at preclinical and early clinical stages of AD. Our preliminary results suggest that the DT paradigm is a sensitive method to detect early signs of neurodegeneration and monitor AD progression.

Superficial Cerebellar Siderosis and Spontaneous Intracranial Hypotension Secondary to Dural Tear.

Spinal dural tears are being increasingly recongnized to cause superficial siderosis and intracranial hypotension. We report a patient with chronic headache who was detected to have cerebellar superficial siderosis and subtle signs of intracranial hypotension on imaging. Spinal imaging showed an upper thoracic dural tear secondary to a paradiscal osteophyte. She improved significantly with surgical repair of the tear. We highlight the importance of recognizing superficial sideorsis in patients with chronic headache as it serves as a marker for dural tear and intracranial hypotension.

Vision Transformers for Lung Segmentation on CXR Images.

Accurate segmentation of the lungs in CXR images is the basis for an automated CXR image analysis system. It helps radiologists in detecting lung areas, subtle signs of disease and improving the diagnosis process for patients. However, precise semantic segmentation of lungs is considered a challenging case due to the presence of the edge rib cage, wide variation of lung shape, and lungs affected by diseases. In this paper, we address the problem of lung segmentation in healthy and unhealthy CXR images. Five models were developed and used in detecting and segmenting lung regions. Two loss functions and three benchmark datasets were employed to evaluate these models. Experimental results showed that the proposed models were able to extract salient global and local features from the input CXR images. The best performing model achieved an F1 score of 97.47%, outperforming recent published models. They proved their ability to separate lung regions from the rib cage and clavicle edges and segment varying lung shape depending on age and gender, as well as challenging cases of lungs affected by anomalies such as tuberculosis and the presence of nodules.

Utilidad y rendimiento diagnóstico de la punción lumbar en el servicio de urgencias

Introducción: la punción lumbar es un procedimiento diagnóstico y terapéutico necesario para muchas enfermedades del sistema nervioso. Con base en la literatura actual, su utilidad en el servicio de urgencias de neurología no ha sido totalmente explorada.
 Objetivos: describir la frecuencia de la punción lumbar en el departamento de urgencias, su utilidad en el diagnóstico de enfermedades del sistema nervioso, y las características demográficas y clínicas más relevantes de los pacientes a quienes se les realizó el procedimiento.
 Materiales y métodos: realizamos un estudio observacional, descriptivo, de corte transversal. Se registraron prospectivamente los datos de todos los pacientes atendidos en el servicio de urgencias de Neurología del Hospital Occidente de Kennedy en Bogotá-Colombia, a quienes se les indicó punción lumbar durante el periodo comprendido entre enero de 2012 a julio de 2013.
 Resultados: se valoraron 3,161 pacientes en urgencias de neurología, y se realizaron 630 punciones lumbares (19,9%). Las principales indicaciones para realizar el procedimiento fueron: cefalea con signos de alarma (40,6%) y sospecha de neuroinfección (27,5%). El 32,2% (IC 95%: 28,5-35,8) de las punciones lumbares tuvo un resultado anormal. La utilidad de la punción lumbar disminuyó en el grupo de pacientes mayores de 65 años (24,5% n=26). Cuando se practica la punción lumbar por sospecha clínica de neuroinfección, la utilidad del procedimiento puede llegar a ser hasta del 40,46% (IC 95%: 33,1- 48,1). El antecedente de VIH tiene una asociación significativa para tener una punción lumbar anormal (p <0.0001). La cefalea (70,9% n= 144) y la fiebre (26,1% n= 53) fueron los síntomas más frecuentes del grupo de pacientes con punción lumbar anormal. La fiebre, los signos meníngeos sutiles y la rigidez nucal, fueron las variables clínicas que presentaron una significancia estadística (p <0,05), y estuvieron asociadas al diagnóstico definitivo de neuroinfección. Dentro de este grupo de pacientes, la alteración de la conciencia (33% n=8) y la rigidez nucal (12,5% n=3) se presentaron con mayor frecuencia en meningitis neutrofílicas comparado con la meningitis linfocitarias. La hipertensión endocraneana idiopática fue el segundo diagnóstico definitivo más frecuente (23,6% n=48), y de estos pacientes, el 62,4% cumplía con criterios clínicos de cefalea crónica diaria.
 Conclusión: la punción lumbar es un procedimiento frecuente y útil en el servicio de urgencias de neurología, que se realiza principalmente en pacientes adultos jóvenes que presenten cefalea con signos de alarma y sospecha clínica de neuroinfección. La infección del sistema nervioso central sigue representando el diagnóstico definitivo más frecuente, y en este grupo de pacientes, el cuadro clínico y las comorbilidades asociadas pueden ayudar a realizar el enfoque etiológico. El alto porcentaje de pacientes con cefalea crónica diaria e hipertensión endocraneana como único hallazgo anormal en la punción lumbar, apoya la hipótesis de que la hipertensión endocraneana idiopática podría ser un factor determinante para la progresión en algunas cefaleas primarias.

RED EARS, RED EYES AND HEARING LOSS: A DIAGNOSTIC DILEMMA

Relapsing polychondritis (RP) is a disease that confounds clinicians worldwide due to the difficulty in confirming its diagnosis and determining the best treatment plan. We report a case of a 34-year-old lady who presented with bilateral inflamed auricular swelling and red eyes, which turned out to be relapsing polychondritis. The patient was successfully treated with long-term oral steroids and is on regular follow-up. This report highlights how the subtle signs of her condition were picked up, leading to her diagnosis of RP and the treatment regime that successfully reversed her symptoms. The challenge of picking up subtle signs of the disease is best met by working as a team in a multidisciplinary setting. A literature study shows that RP is a rare disease that can present with many symptoms.

Shifting from Left Ventricular Ejection Fraction to Strain Imaging in Aortic Stenosis.

Adverse ventricular remodeling is an inflexion point of disease progression in aortic stenosis (AS) and a major determinant of prognosis. Intervention before irreversible myocardial damage is of paramount importance to sustain favorable post-operative outcomes. Current guidelines recommend a left ventricular ejection fraction (LVEF)-based strategy to determine the threshold for intervention in AS. However, LVEF has several pitfalls: it denotes the left ventricular cavity volumetric changes and it is not suited to detecting subtle signs of myocardial damage. Strain has emerged as a contemporary imaging biomarker that describes intramyocardial contractile force, providing information on subclinical myocardial dysfunction due to fibrosis. A large body of evidence advocates its use to determine the switch from adaptive to maladaptive myocardial changes in AS, and to refine thresholds for intervention. Although mainly studied in echocardiography, studies exploring the role of strain in multi-detector row computed tomography and cardiac magnetic resonance are emerging. This review, therefore, summarizes contemporary evidence on the role of LVEF and strain imaging in AS prognosis, aiming to move from an LVEF-based to a strain-based approach for risk stratification and therapeutic decision-making in AS.

Critical care nurses’ experiences of caring for patients with iatrogenic opioid withdrawal in the intensive care unit: A qualitative study

ObjectivesTo explore critical care nurses’ experiences of caring for adult patients experiencing iatrogenic opioid withdrawal in the intensive care unit. Research methodology/designA qualitative study with an explorative and descriptive design was conducted. Data were collected through semi-structured interviews and systematic text condensation was used to analyse the data. The study was reported according to the consolidated criteria for reporting qualitative research checklist. Setting and participantsTen critical care nurses, working at three different intensive care units in two university hospitals in Norway. FindingsThree categories were identified in the data analysis. “Subtle signs and symptoms of opioid withdrawal”, lack of a systematic approach to opioid withdrawal, and the prerequisites for appropriate management of opioid withdrawal. Critical care nurses experienced challenges in identifying opioid withdrawal due to subtle and vague signs and symptoms, especially when not knowing their patient or when difficulties were encountered with patient communication. A systematic approach to opioid withdrawal and increased knowledge, definitive plans for weaning, as well as interdisciplinary unity and collaboration, could improve the management of opioid withdrawal. ConclusionValidated assessment tools, systematic strategies, and guidelines are essential for the management of opioid withdrawal in opioid naïve patients in intensive care units. The prerequisites for an appropriate management of opioid withdrawal are an accurate and effective communication among critical care nurses and other healthcare professionals involved in patient care. Implications for clinical practiceThere is a need for a validated assessment tool, systematic strategies, and guidelines for the management of opioid withdrawal in opioid naïve patients in intensive care units. Increased emphasis needs to be placed on the process of identifying iatrogenic opioid withdrawal and improving opioid withdrawal management in the education system and clinical practice.

Pre-existing frontal lobe dysfunction signs as predictors of subsequent neurotoxicity in CAR T cell therapy: insights from a case series.

Chimeric Antigen Receptor (CAR) T cell therapies are innovative treatments against hematological malignancies, with increasing therapeutic indications. Despite their great efficacy, these therapies are hampered by high rates of neurotoxicity (immune effector cell-associated neurotoxicity (ICANS)). In the past few years, several risk factors have been associated with ICANS and grouped together in the attempt to build validated models able to predict neurologic complications. However, little is known about pre-existing neurologic conditions possibly related to the development of neurotoxicity. In our case series, including sixteen consecutive patients treated with CAR T cells, we observed that (i) neurotoxicity only occurred in the two patients who presented subtle clinical signs of frontal lobe impairment at baseline and (ii) neurologic manifestations of ICANS consisted of language disturbances and cortical frontal myoclonus, which were both manifestations of a frontal predominant dysfunction. Based on our experience, we suggest that a pre-existing frontal lobe impairment, even if at a subclinical level, may eventually drive to ICANS, which in turn shows symptoms compatible with a frontal encephalopathy. It is remarkable that this focal neurotoxicity involved the same CNS regions that were responsible of subtle neurological signs at baseline. Future studies on larger numbers of patients are needed to confirm the possible role of baseline frontal lobe dysfunction as a predictor of ICANS, in order to enhance efforts to safely deliver CAR T cell therapy.

Syringomyelia secondary to thoracic spinal dural arteriovenous fistula presenting as paraparesis.

Spinal dural arteriovenous fistula (SDAVF) is also known as a type 1 spinal arteriovenous malformation, representing the most frequent vascular malformation of the spine. A high suspicion index is often required for the initial diagnosis of SDAVF because of subtle magnetic resonance imaging signs. We present the case of a patient with SDAVF associated with syringomyelia of the thoracic spinal cord and hypothesize that a fistula might induce intramedullary fluid accumulation due to venous hypertension, which leads to syrinx formation.

Abstract #1407996: Co-secreting Pituitary Tumors: A Clinical Challenge

Co-secreting pituitary adenomas are rare, with complex clinical presentation and challenging long-term management. We present a small case series of co-secreting pituitary tumors, highlighting the importance of evaluating all pituitary hormones in the setting of a pituitary adenoma. Case 1: Active acromegaly with a functioning pituitary FSHoma A 46-year-old married male, presented with bilateral vision loss, headache, and weight gain for the last 18 months. He had also noticed enlarging hands and decreased libido. He was obese (BMI of 32.2 Kg/m2). Red reflex was present in the right eye, while temporal hemianopia was noted in the left eye. He had phenotypic features of acromegaly, had enlarged testicles measuring more than 25mls bilaterally. Acromegaly and FSHoma were confirmed with raised IGF-1 levels (733.70 ng/ml) and FSH levels, checked twice (108.9 & 107 mIU/ml respectively) with low LH (2.40 mIU/ml) and T (1.27 pg/ml); PRL, ACTH, and TSH were normal. MRI pituitary revealed a large mass measuring ∼ 2.9 x 3.6 x 4.7 cm. He was referred for pituitary surgery but was lost to follow-up thereafter. Case 2, 3, 4, 5: Acromegaly with co-secretion of prolactin Two single females, aged 18, and 33; one married, aged 33, and a 23-year-old single male presented with enlarging hands and feet and weight gain. All females had secondary amenorrhoea and galactorrhoea. A male patient and two of the females also had headaches and visual disturbances. The youngest of them did not have any classical signs of acromegaly but had bitemporal hemianopia. The male patient had right-sided temporal hemianopia. They all had raised IGF-1 levels (1195.0, 701.0, 1136.0, & 516.7ng/mL). PRL levels were 458.1, 303.0, 53.0, and 1825 ng/ml. Their LH, FSH, and FT4 levels were low. All had normal ACTH and Cortisol levels. MRI pituitary revealed pituitary macroadenomas. All were started with cabergoline and referred for surgery. Only the youngest patient underwent surgery. The other three declined surgery for the time being and were started on monthly long-acting Octreotide. Case 6: Prolactinoma with late co-secretion of growth hormone A 40-year-old female, with a history of micro prolactinoma diagnosed in 2004, recently presented in 2021 with complaints of enlarging hands and feet. There was no history of headache or visual symptoms. She presented, 16 years ago with secondary amenorrhoea with isolated hyperprolactinemia. Her MRI showed a pituitary mass measuring 1.2 x1.6 cm. Since that time, she was on cabergoline. She also had subtle signs of acromegaly. Showed raised IGF-1 (410.0) and GH nadir of 3.12mcg/L after a 75 g oral glucose challenge. Her FSH, LH, Estradiol, FT4, and cortisol were normal, while PRL was raised (49.6 ng/ml). Her cabergoline dose was increased and was referred for Trans-sphenoidal surgery. The literature review revealed a very rare synchronous presentation of acromegaly and FSH-secreting pituitary adenoma. FSH and FSHoma is specified in the etiology of macroorchidism, as present in our case. Up to 25% of GH adenomas co-secrete prolactin. The Third Type occurs due to Primitive acidophilic stem cell adenomas with dual hormone secretion from a single cell.

Pituitary adenoma consecrating GH and ACTH: A rare case report

Plurihormonal Pituitary adenoma is defined as an adenoma that expresses more than one hormone on immunohistochemistry. The most common combination in these adenomas includes growth hormone (GH) and prolactin (PRL). We describe an interesting case of plurihormonal pituitary adenoma with double hormonal staining for adrenocorticotrophic hormone (ACTH) and GH in a patient who presented with acromegaly and subtle signs of Cushing disease due to a large pituitary macroadenoma

Optokinetic Nystagmus: Five Reasons Why Every Neurologist Should Evaluate It (P3-9.006)

<h3>Objective:</h3> To highlight the clinical utility of optokinetic nystagmus (OKN) through five illustrative video cases. <h3>Background:</h3> Bedside evaluation of OKN allows for rapid assessment of smooth pursuit (slow phase) and saccades (fast phase). Specific abnormalities of OKN have localizing value and may also suggest specific neurologic disorders. <h3>Design/Methods:</h3> We provide five video cases where OKN was helpful in localization and/or diagnosis. Video cases are provided from https://novel.utah.edu/Gold/. <h3>Results:</h3> (1) OKN can be used to make an early diagnosis of progressive supranuclear palsy before there is ophthalmoparesis. Vertical OKN can demonstrate absent or attenuated saccades, particularly when compared to a normal response to horizontal OKN. (2) A subtle sign of internuclear opthalmoparesis, when there is no obvious limitation of adduction, can be demonstrated with horizontal OKN by noting a slow (lagging) adducting saccade. (3) In patients with dorsal midbrain (Parinaud) syndrome, upgaze is often limited or absent, and the characteristic finding of convergence-retraction nystagmus (CRN) can be easily appreciated when an optokinetic stimulus is moved downward (e.g., downward slow phase followed by CRN instead of an upward fast phase). (4) Patients with a homonymous hemianopsia due to an occipital lesion will have normal OKN; whereas, patients with a homonymous hemianopsia due to a parietal lesion will have absent OKN when the stimulus is directed toward the side of the lesion. (5) In patients who claim to have binocular or monocular blindness, the presence of OKN (when monocular, with the good eye covered) is highly suggestive of functional vision loss. Observing OKN does not prove that the patient’s visual function is normal, but does rule out blindness. <h3>Conclusions:</h3> Assessing optokinetic nystagmus with a flag, tape, drum, or the examiner’s fingertips is a portable, inexpensive, and rapid bedside examination to localize and diagnose a variety of neurologic and neuro-ophthalmic disorders. <b>Disclosure:</b> Dr. Hale has nothing to disclose. Dr. Reich has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Best Doctors. Dr. Reich has received personal compensation in the range of $500-$4,999 for serving as a Consultant for UpToDate. Dr. Reich has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Enterin. Dr. Reich has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for NIH. Dr. Reich has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Various law firms. The institution of Dr. Reich has received research support from ninds. Dr. Reich has received publishing royalties from a publication relating to health care. Dr. Reich has received publishing royalties from a publication relating to health care. Dr. Gold has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Springer .

Discovering a pregnancy after 30 weeks: a qualitative study on explanations for unperceived pregnancy

“Unperceived pregnancy” names the phenomenon when a person becomes pregnant unintentionally and is not aware of being pregnant. Scientific explanations are roughly based on two hypotheses: psychological and physiological. We aim to gain a better understanding of unperceived pregnancy by studying the perspectives of people who experienced an unperceived pregnancy and obstetric professionals. Seventeen semi-structured interviews were conducted: eight with women who had experienced an unperceived pregnancy (≥30 weeks’ gestation), six with midwives, and three with gynecologists. Our findings show that women’s explanations for not noticing their pregnancy center around the absence of pregnancy symptoms. The failure to recognize more subtle signs of pregnancy was enforced by inattention, physical distractions, and psychological factors. In contrast, psychological explanations are dominant among obstetric professionals. Our study demonstrates a discrepancy in the explanations provided by women who had experienced an unperceived pregnancy and obstetric professionals. Potentially, this could result in people being unheard and misunderstood. We recommend that future research moves beyond a focus on “denial of pregnancy” to consider both psychological and physiological factors, and how these could potentially interrelate. This broadened approach will enhance our understanding of unperceived pregnancy and can contribute to improved counseling by obstetric professionals.

The experience of being a partner to a childbearing woman whose pregnancy is complicated by pre-eclampsia: A Swedish qualitative study

BackgroundPre-eclampsia affects 3–5% of all pregnant women and is among the leading causes of maternal morbidity and mortality as well as iatrogenic preterm birth worldwide. Little is known about the experience of partners of women whose pregnancy is complicated by pre-eclampsia. AimTo describe partners’ experience of having a spouse whose pregnancy was complicated by pre-eclampsia. MethodsA qualitative study with in-depth interviews. Eight partners of women whose pregnancy was complicated by pre-eclampsia were interviewed and data were analysed using content analysis. FindingsPartners found themselves in an unfamiliar and unexpected situation. They experienced an information gap in which they tried to make sense of the situation by interpreting subtle signs. The situation left them feeling emotionally stretched, feeling like an outsider while trying to provide support for their extended family. The partners experienced a split focus after the baby was born, prioritising the baby while worrying about their spouse. Post-partum, they expressed needing time to process and heal after childbirth. A need for professional support was highlighted and concerns about a future pregnancy were voiced. ConclusionHaving a spouse who is diagnosed with pre-eclampsia is challenging and overwhelming. Our findings imply a need to develop a model of care for women with pre-eclampsia that includes their partner, i.e., the other parent.

Proposal of multimodal computed tomography-based scoring system in prediction of hemorrhagic transformation in acute ischemic stroke.

The routinely used computed tomography (CT)-based workup in the setting of acute ischemic stroke (AIS) includes non-contrast brain CT, CT angiography (CTA), and CT perfusion. Several CT, CTA, CTP-based radiological biomarkers of hemorrhagic transformation (HT) were reported. To assess the predictive value of the combined multimodal CT parameters for HT after AIS and proposal of predictive scoring scale. The source images of the NCCT, CTA and CTP of 282 AIS patients involving the anterior circulation (HT = 91, non-HT = 191) were retrospectively reviewed and the following biomarkers were recorded and analyzed: Early subtle ischemic signs, hyperdense middle cerebral artery sign (HMCAS) and Alberta Stroke Program Early CT Score (ASPECTS) < 7 in NCCT, large-vessel occlusion (LVO), clot burden score (CBS) < 6, large-vessel occlusion, poor collateral score (CS) and Tmax > 6s ≥ 56.5ml. A scoring system to predict HT based on these biomarkers was developed. Each biomarker counts for a single point with the total score ranging from 0 to 7. All the aforementioned multimodal CT biomarkers and the selected cut offs were significantly associated with higher HT risk. The calculated scores were statistically significant different between the HT and the non-HT groups with AUC 0.761 (95% CI 0.703-0.819, P < 0.0000001). Rates of HT were approximately five times higher in patients with score ≥ 3. Multimodal CT-based scoring system may provide highly reliable predictive model of hemorrhagic transformation in acute ischemic stroke.

Rethinking recovery in adolescent concussions: Network-level functional connectivity alterations associated with motor deficits.

Adolescents who are clinically recovered from concussion continue to show subtle motor impairment on neurophysiological and behavioral measures. However, there is limited information on brain-behavior relationships of persistent motor impairment following clinical recovery from concussion. We examined the relationship between subtle motor performance and functional connectivity of the brain in adolescents with a history of concussion, status post-symptom resolution, and subjective return to baseline. Participants included 27 adolescents who were clinically recovered from concussion and 29 never-concussed, typically developing controls (10-17 years); all participants were examined using the Physical and Neurologic Examination of Subtle Signs (PANESS). Functional connectivity between the default mode network (DMN) or dorsal attention network (DAN) and regions of interest within the motor network was assessed using resting-state functional magnetic resonance imaging (rsfMRI). Compared to controls, adolescents clinically recovered from concussion showed greater subtle motor deficits as evaluated by the PANESS and increased connectivity between the DMN and left lateral premotor cortex. DMN to left lateral premotor cortex connectivity was significantly correlated with the total PANESS score, with more atypical connectivity associated with more motor abnormalities. This suggests that altered functional connectivity of the brain may underlie subtle motor deficits in adolescents who have clinically recovered from concussion. More investigation is required to understand the persistence and longer-term clinical relevance of altered functional connectivity and associated subtle motor deficits to inform whether functional connectivity may serve as an important biomarker related to longer-term outcomes after clinical recovery from concussion.