Faculty Bibliography

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.

BACKGROUND AND PURPOSE: Reducing door-to-imaging (DIT) time is a major focus of acute stroke quality improvement initiatives to promote rapid thrombolysis. However, recent data suggest that the imaging-to-needle (ITN) time is a greater source of treatment delay. We hypothesized that language discordance between physician and patient would contribute to prolonged ITN time, as rapidly taking a history and confirming last known well require facile communication between physician and patient. METHODS: This is a retrospective analysis of all patients who received tissue plasminogen activator (tPA) in our emergency department between July 2011 and December 2014. Baseline characteristics and relevant time intervals were compared between encounters where the treating neurologist and patient spoke the same language (concordant cases) and where they did not (discordant cases). RESULTS: A total of 279 patients received tPA during the study period. English was the primary language for 51%, Spanish for 46%, and other languages for 3%; 59% of cases were classified as language concordant and 41% as discordant. We found no differences in median DIT (24 vs 25, P = .5), ITN time (33 vs 30, P = .3), or door-to-needle time (DTN; 58 vs 55, P = .1) between concordant and discordant groups. Similarly, among patients with the fastest and slowest ITN times, there were no differences. CONCLUSION: In a high-volume stroke center with a large proportion of Spanish speakers, language discordance was not associated with changes in DIT, ITN time, or DTN time.

IMPORTANCE: Neurological worsening and recurrent stroke contribute substantially to morbidity associated with transient ischemic attacks and strokes (TIA-S). OBJECTIVE: To determine predictors of early recurrent cerebrovascular events (RCVEs) among patients with TIA-S and National Institutes of Health Stroke Scale scores of 0 to 3. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted at 2 tertiary care centers (Columbia University Medical Center, New York, New York, and Tulane University Medical Center, New Orleans, Louisiana) between January 1, 2010, and December 31, 2014. All patients with neurologist-diagnosed TIA-S with a National Institutes of Health Stroke Scale score of 0 to 3 who presented to the emergency department were included. MAIN OUTCOMES AND MEASURES: The primary outcome (adjudicated by 3 vascular neurologists) was RCVE: neurological deterioration in the absence of a medical explanation or recurrent TIA-S during hospitalization. RESULTS: Of the 1258 total patients, 1187 had no RCVEs and 71 had RCVEs; of this group, 750 patients (63.2%) and 39 patients (54.9%), respectively, were aged 60 years or older. There were 505 patients with TIA-S at Columbia University; 31 (6.1%) had RCVEs (15 patients had neurological deterioration only, 11 had recurrent TIA-S only, and 5 had both). The validation cohort at Tulane University consisted of 753 patients; 40 (5.3%) had RCVEs (24 patients had neurological deterioration only and 16 had both). Predictors of RCVE in multivariate models in both cohorts were infarct on neuroimaging (computed tomographic scan or diffusion-weighted imaging sequences on magnetic resonance imaging) (Columbia University: not applicable and Tulane University: odds ratio, 1.75; 95% CI, 0.82-3.74; P = .15) and large-vessel disease etiology (Columbia University: odds ratio, 6.69; 95% CI, 3.10-14.50 and Tulane University: odds ratio, 8.13; 95% CI, 3.86-17.12; P < .001). There was an increase in the percentage of patients with RCVEs when both predictors were present. When neither predictor was present, the rate of RCVE was extremely low (up to 2%). Patients with RCVEs were less likely to be discharged home in both cohorts. CONCLUSIONS AND RELEVANCE: In patients with minor stroke, vessel imaging and perhaps neuroimaging parameters, but not clinical scores, were associated with RCVEs in 2 independent data sets. Prospective studies are needed to validate these predictors.

STUDY OBJECTIVES: To examine the association between markers of sleep-disordered breathing (SDB) and white matter hyperintensity (WMH) volume in an elderly, multiethnic, community-dwelling cohort. METHODS: This is a cross-sectional analysis from the Washington Heights-Inwood Columbia Aging Project (WHICAP), a community-based epidemiological study of older adults. Structural magnetic resonance imaging was obtained starting in 2004; the Medical Outcomes Study-Sleep Scale (MOS-SS) was administered to participants starting in 2007. Linear regression models were used to assess the relationship between the two MOS-SS questions that measure respiratory dysfunction during sleep and quantified WMH volume among WHICAP participants with brain imaging. RESULTS: A total of 483 older adults had both structural magnetic resonance imaging and sleep assessment. Self-reported SDB was associated with WMH. After adjusting for demographic and vascular risk factors, WMH volumes were larger in individuals with frequent snoring (beta = 2.113, P = 0.004) and among those who reported waking short of breath or with headache (beta = 1.862, P = 0.048). CONCLUSIONS: In community-dwelling older adults, self-reported measures of SDB are associated with larger WMH volumes. The cognitive effects of SDB that are increasingly being recognized may be mediated at the small vessel level.