Faculty Bibliography

BACKGROUND: Prior studies have shown a correlation between the National Institutes of Health Stroke Scale (NIHSS) and stroke volume on diffusion weighted imaging (DWI); data are more limited in patients with minor stroke. We sought to determine the association between DWI lesion(s) volume and the (1) total NIHSS score and (2) NIHSS component scores in patients with minor stroke. METHODS: We included all patients with minor stroke (NIHSS 0-5) enrolled in the Stroke Warning Information and Faster Treatment study. We calculated lesion(s) volume (cm3 ) on the DWI sequence using Medical Image Processing, Analysis, and Visualization (MIPAV, NIH, Version 7.1.1). We used nonparametric tests to study the association between the primary outcome, DWI lesion(s) volume, and the predictors (NIHSS score and its components). RESULTS: We identified 894 patients with a discharge diagnosis of minor stroke; 709 underwent magnetic resonance imaging and 510 were DWI positive. There was a graded relationship between the NIHSS score and median DWI lesion volume in cm3 : (NIHSS 0: 7.1, NIHSS 1: 8.0, NIHSS 2: 17.1, NIHSS 3: 11.6, NIHSS 4: 19.0, and NIHSS 5: 23.6, P < .01). The median lesion volume was significantly higher in patients with neglect (105.6 vs. 12.5, P = .025), language disorder (34.6 vs. 11.9, P < .001), and visual field impairment (185.6 vs. 11.6, P < .001). Other components of the NIHSS were not associated with lesion volume. CONCLUSION: In patients with minor stroke, the nature of deficit when used with the NIHSS score can improve prediction of infarct volume. This may have clinical and therapeutic implications.

Objective: To describe a spinal cord infarct masquerading as brown-sequard syndrome. Background: Spinal cord infarcts have historically been difficult to diagnose both clinically and radio-graphically. For appropriate treatment, infarcts must be differentiated early from infectious or demyelinating etiologies. Improved MRI resolution and pattern recognition can separate these entities, even in atypical cases. Design/Methods: Clinical case, diagnostics, imaging and literature review. Results: A 64-year-old woman with history of uncontrolled type II diabetes presented with urinary retention, left lower extremity (LLE) pain and progressive LLE weakness over 10 hours. Upon arrival, exam showed isolated LLE plegia, decreased pain and temperature sensation in the right lower extremity, and a T5 sensory level. Reflexes were symmetric except for a left Babinski sign. Spinal cord MRI revealed asymmetric abnormal signal in the upper thoracic cord with minimal edema and no enhancement. Diffusion sequencing was consistent with infarct. CT angiogram of the neck showed no dissection or large-vessel disease. Within 36 hours of hospitalization patient developed acute hypoxemia and was found to have bilateral saddle pulmonary emboli leading to cardiac arrest. She was resuscitated, received thrombolytics and underwent surgical thrombectomy. It was theorized that brief immobility on background of hypercoagulable state caused a large embolic burden. Neurologic exam remained stable despite her complicated course. She was treated with high-dose statin and anticoagulation. Hypercoagulability panel, including genetic and antiphospholipid antibody testing, was negative. Conclusions: Clinical symptoms of sub-acute LLE plegia and brown-sequard-like sensory disturbance initially forced us to consider infectious and inflammatory etiologies. Although spinal anatomy is notoriously variable, hemi-cord localization was still difficult to explain with an anterior spinal artery infarct. Lack of enhancement, minimal expansion and diffusion restriction on MRI are useful in differentiating infarct from demyelination. With this knowledge and patient's propensity to clot, we felt confident calling this an atypical spinal cord infarct explained by unique collateral circulation

BACKGROUND: Acute stroke is a time-sensitive condition in which rapid diagnosis must be made in order for thrombolytic treatment to be administered. A certain proportion of patients who receive thrombolysis will be found on further evaluation to have a diagnosis other than stroke, so-called "stroke mimics." Little is known about the role of language discordance in the emergency department diagnosis of acute ischemic stroke. METHODS: This is a retrospective analysis of all acute ischemic stroke patients who received IV tissue plasminogen activator (tPA) in our emergency department between July 2011 and December 2015. Baseline characteristics, patient language, and final diagnosis were compared between encounters in which the treating neurologist and patient spoke the same language (concordant cases) and encounters in which they did not (discordant cases). RESULTS: A total of 350 patients received IV tPA during the study period. English was the primary language for 52.6%, Spanish for 44.9%, and other languages for 2.6%; 60.3% of cases were classified as language concordant and 39.7% as discordant. We found no significant difference in the proportion of stroke mimics in the language concordant compared to discordant groups (16.6% vs 9.4%, p = 0.06). Similarly, the proportion of stroke mimics did not differ between English- and Spanish-speaking patients (15.8% vs 11.5%, p = 0.27). CONCLUSIONS: Language discordance was not associated with acute stroke misdiagnosis among patients treated with IV tPA. Prospective evaluation of communication during acute stroke encounters is needed to gain clarity on the role of language discordance in acute stroke misdiagnosis.