The Neurologist[JOURNAL]
Sun
200 papers
Artificial Intelligence in the Prehospital Stage of Stroke: Can Virtual Assistants Optimize Triage?
Alessandro L, Crema S, Bianciotti N … +7 more , Lombán J, Perez Arana CI, Bordón Orsingher FG, Kañevsky AL, Pujol-Lereis V, Fernandez Slezak D, Farez MF
Neurologist · 2026 Jun · PMID 42391584 · Publisher ↗
OBJECTIVES: Many patients fail to access emergency services in time for acute stroke treatment. Artificial intelligence (AI) may help optimize prehospital triage. This study describes the development, refinement, and cli...
OBJECTIVES: Many patients fail to access emergency services in time for acute stroke treatment. Artificial intelligence (AI) may help optimize prehospital triage. This study describes the development, refinement, and clinical validation of an AI-based virtual assistant (VA) for early stroke detection and appropriate emergency referral. METHODS: A prospective cohort study was conducted between August 2024 and July 2025 in a tertiary care center in Buenos Aires, Argentina. The VA was applied to adult inpatients with acute stroke in a neurovascular unit. Before this, the tool had been optimized using a literature review and simulations with 1151 de-identified medical records. Clinical, demographic, and performance variables were recorded. The main outcomes were syndromic diagnostic alignment, identification of the most probable diagnosis, appropriate emergency referral, and user satisfaction. RESULTS: A total of 78 participants were included (median age: 73 y; 56.4% male). The mean time from symptom onset to VA use was 2 days. Final diagnoses were ischemic stroke (80.8%), transient ischemic attack (11.5%), subarachnoid hemorrhage (5.1%), and intracerebral hemorrhage (2.6%). Syndromic diagnosis matched the clinical standard in 89.7% of cases; top-1 match in 71.8%, and top-3 in 91%. Emergency referral was adequate in 93.6% of cases. The median use involved 10 questions and 4 minutes. Over 90% rated the experience 4 or 5 out of 5. CONCLUSIONS: In this controlled validation involving patients with confirmed cerebrovascular disease, the AI-based VA demonstrated high agreement with clinical syndromic classification, appropriate urgency recommendations, and high user acceptance. Further evaluation in broader prehospital populations is warranted.
Looking Beyond the Midline: An Uncommon Etiology of Internuclear Ophthalmoplegia of Abduction Due to Cerebral Venous Thrombosis.
Baskar D, Maheswarappa AG
Neurologist · 2026 Jun · PMID 42348748 · Publisher ↗
INTRODUCTION: Internuclear ophthalmoplegia (INO) is a horizontal gaze disorder caused by medial longitudinal fasciculus lesions. INO of abduction is an exceptionally rare variant characterized by abduction limitation wit...
INTRODUCTION: Internuclear ophthalmoplegia (INO) is a horizontal gaze disorder caused by medial longitudinal fasciculus lesions. INO of abduction is an exceptionally rare variant characterized by abduction limitation with preserved convergence and contralateral adduction nystagmus, with unclear pathophysiology, and only a limited number of cases have been reported. CASE REPORT: A 27-year-old man presented with headache, vomiting, seizures, and altered sensorium. Examination revealed bilateral disc edema and abduction restriction of the right eye, with contralateral adduction nystagmus, consistent with INO of abduction. Brain MRI showed no brainstem lesions, while MR venography demonstrated cerebral venous thrombosis of the superior sagittal, left transverse, and sigmoid sinuses. Vitamin B12 deficiency with hyperhomocysteinemia was detected. Treatment with anticoagulation and acetazolamide resulted in complete resolution of the ocular motility deficits. CONCLUSION: This case highlights a reversible form of INO of abduction associated with raised intracranial pressure in the absence of structural brainstem lesions, likely due to pressure-mediated disruption of inhibitory gaze pathways. INO of abduction is an ultrarare but clinically important sign. Its recognition in patients with intracranial hypertension and normal brainstem imaging may aid in localization and facilitate timely, reversible treatment.
Commentary: Cervical Artery Dissection and Chiropractic Cervical Manipulation: Clarifying Association, Mechanism, and Interpretation.
Maalouf N, Yaghi S
Neurologist · 2026 Jun · PMID 42348731 · Publisher ↗
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Acute Spinal Cord Infarct Secondary to Fibrocartilaginous Embolism Treated With Tenecteplase.
Patel J, Kamireddi P, Jacob S
Neurologist · 2026 Jun · PMID 42348726 · Publisher ↗
INTRODUCTION: Fibrocartilaginous embolism is a rare cause of spinal cord infarction. It can affect young healthy adults during physical exertion or the Valsalva maneuver. There is little evidence behind a fibrocartilagin...
INTRODUCTION: Fibrocartilaginous embolism is a rare cause of spinal cord infarction. It can affect young healthy adults during physical exertion or the Valsalva maneuver. There is little evidence behind a fibrocartilaginous embolism causing spinal cord infarctions. The efficacy of thrombolytic therapy in spinal cord infarction is not well established. CASE REPORT: A 56-year-old male with hypertension presented with acute onset left arm and leg weakness after a Valsalva maneuver. The exam was remarkable for dense flaccid paralysis of the left arm and leg. Patient received thrombolytic therapy for suspicion of stroke. MRI C-spine revealed a nonenhancing lesion from C2 to C5 with diffusion restriction on DWI, suggesting a spinal infarct. He received 5 days of high-dose steroids with mild improvement of left lower extremity weakness. Labs were unremarkable for underlying inflammatory or demyelinating causes of myelopathy. We ruled out aortic dissection and cardioembolic causes. Upon further evaluation, the patient endorsed lifting heavy weights and had cervical spondylosis on imaging, which led to the diagnosis of fibrocartilaginous embolism. On 1-year follow-up, he is walking without support with some motor improvement in the distal left upper extremity. CONCLUSIONS: It is important to have a wide differential diagnosis in acute cases of myelopathy. In our patient's case, his diagnosis was one of exclusion. This case highlights a rare cause of spinal cord infarction in a middle-aged man. The efficacy of thrombolytic therapy in such cases needs further investigation.
Cervical Artery Dissection and Chiropractic.
Tuchin P, Wilder J, Farabaugh R … +2 more , Demetrious J, Graber DI
Neurologist · 2026 Jun · PMID 42348260 · Publisher ↗
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Oromandibular Dyskinesia Associated With Levofloxacin and Responsive to Low-Dose Oral Diazepam: A Case Report.
Mert A, Ayar DA
Neurologist · 2026 May · PMID 42234980 · Publisher ↗
INTRODUCTION: Oromandibular dyskinesia (OMD) is a rare movement disorder characterized by involuntary, repetitive, and often uncontrolled movements of the jaw, lips, and tongue. It may be associated with antipsychotics,...
INTRODUCTION: Oromandibular dyskinesia (OMD) is a rare movement disorder characterized by involuntary, repetitive, and often uncontrolled movements of the jaw, lips, and tongue. It may be associated with antipsychotics, antidepressants, anticonvulsants, and antibiotics. The OMD caused by antibiotics is very rare and often overlooked. CASE REPORT: We report here an 89-year-old female patient who had chewing-like oromandibular dyskinesia, defined by vertical jaw opening and closing motions, on the third day of oral levofloxacin medication, which began for community-acquired pneumonia. After cessation of levofloxacin and initiation of low-dose diazepam (5 mg/d), dramatic clinical improvement was observed within 48 hours, with symptoms nearly fully resolved by day 7. CONCLUSIONS: Fluoroquinolones can rarely cause movement disorders like OMD. The exact mechanism is unknown, but it may involve GABA imbalance. Stopping the drug and starting benzodiazepines may lead to a fast recovery.
Spinal H-Sign in Syphilitic Myelitis Mimicking MOGAD.
Akrivaki A, Karamanidis S, Dimitriadou EM … +6 more , Theodorou A, Kitsos D, Tzanetakos D, Tzartos JS, Tsivgoulis G, Giannopoulos S
Neurologist · 2026 Jun · PMID 42224436 · Publisher ↗
INTRODUCTION: Longitudinally extensive transverse myelitis (LETM) is classically associated with aquaporin-4 antibody-mediated neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-assoc...
INTRODUCTION: Longitudinally extensive transverse myelitis (LETM) is classically associated with aquaporin-4 antibody-mediated neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). The "H-sign," reflecting gray matter involvement, is considered suggestive of MOGAD. However, infectious etiologies, including neurosyphilis, may rarely mimic autoimmune inflammatory myelopathies radiologically. CASE REPORT: A 50-year-old man presented with 6 months of erectile dysfunction and urinary retention, followed by progressive gait instability. Examination revealed spastic paraparesis with tetrapyramidal signs, saddle hypoesthesia, and impaired vibration sense. Thoracic spine MRI demonstrated LETM from T4 to T10 with central gray matter involvement forming the "H-sign." Postcontrast sequences showed intense pial and intramedullary enhancement with inversion of signal intensity ("flip-flop sign"), suggestive of inflammatory meningomyelitis. Brain MRI was normal. Serum treponemal tests were reactive, and cerebrospinal fluid analysis revealed lymphocytic pleocytosis, elevated protein, and positive VDRL, confirming neurosyphilis. MOG-IgG and AQP4-IgG were negative using validated cell-based assays. The patient received intravenous benzylpenicillin combined with high-dose corticosteroids, resulting in significant clinical improvement and partial radiologic resolution at 6 months. CONCLUSION: Neurosyphilis is a rare but treatable cause of LETM and may radiologically mimic antibody-mediated demyelinating disorders, including MOGAD. The coexistence of the "H-sign" and the flip-flop enhancement pattern highlights the diagnostic overlap between infectious and autoimmune myelitis. Careful exclusion of infectious etiologies remains essential in patients presenting with LETM to ensure appropriate therapy and avoid unnecessary immunosuppression.
Hitting A Nerve: T1 Nerve Root Injury Secondary to Open Heart Surgery.
Varda N, Saunders JA, Varkey TC … +2 more , Behzadi F, Singh S
Neurologist · 2026 May · PMID 42224184 · Publisher ↗
INTRODUCTION: Patients who undergo cardiothoracic surgery and sternotomy can experience cardiovascular complications from manipulation of the great vessels or artificial pump bypass of the heart, raising the fear of stro...
INTRODUCTION: Patients who undergo cardiothoracic surgery and sternotomy can experience cardiovascular complications from manipulation of the great vessels or artificial pump bypass of the heart, raising the fear of stroke in the setting of focal neurological deficit. However, this study reveals a less common but often as focal and debilitating complication of these surgeries from direct injury of the peripheral nerves under prolonged physical tension. CASE STUDY: This case details the presentation of a 72-year-old woman who developed acute left upper extremity weakness following elective open-heart surgery. Imaging ruled out ischemic or hemorrhagic stroke, and instead revealed a brachial plexus injury, with the most severe injury being on the T1 nerve root. This injury, leading to left upper extremity weakness, was diagnosed after advanced imaging and physical examination. The patient's symptoms gradually improved with supportive management and physical therapy. CONCLUSION: This case underscores the importance of considering nerve injuries in the differential diagnosis of postoperative weakness and highlights the role of advanced imaging and electromyography in confirming brachial plexus injuries. Early recognition and appropriate management are essential for optimizing recovery in patients with iatrogenic brachial plexopathy.
Frequency of Abnormal Neurological Examinations in a Subspecialty Headache Clinic: A Retrospective Chart Review.
Leung SW, Iverson OC, Green AL
Neurologist · 2026 May · PMID 42224091 · Publisher ↗
OBJECTIVES: Identify the frequency of abnormal neurological examinations among patients presenting in person for headache consultation. Determine what proportion of patients with abnormal examinations have accompanying r...
OBJECTIVES: Identify the frequency of abnormal neurological examinations among patients presenting in person for headache consultation. Determine what proportion of patients with abnormal examinations have accompanying red flags in their histories and/or undergo diagnostic workup. METHODS: We conducted a retrospective review of patients presenting in person for headache consultation at a tertiary/quaternary headache clinic between June 2022 and May 2023. We excluded examination abnormalities consistent with known comorbidity, functional neurological disorder, and/or non-headache disease. We then calculated the proportion of patients with an abnormal neurological examination. For patients with abnormal examinations, the electronic medical record was further reviewed for red-flag components in the history, diagnostic workup ordered, and the resulting diagnosis. RESULTS: Of 1281 patients presenting for in-person headache consultation, 218 (17%) had abnormal neurological examinations that were not consistent with known comorbidity, functional neurological disorder, or non-headache disease. Of these, 203 (93%) had a red flag in their history. The remaining 15 patients with abnormal examinations and no historical red flags comprised 1.2% of all 1281 patients. Regarding workup, 160 (73%) had neuro-imaging and 61 (28%) had laboratory studies ordered and/or requested for review, of which 13% and 8% were concerning for pathology, respectively. CONCLUSIONS: A small but notable proportion of patients presenting for in-person headache consultation had abnormalities on neurological examination. The majority of these patients received imaging, with a diagnostic yield higher than previously reported. However, the vast majority of patients with abnormal examinations also had red flags in their history to prompt diagnostic workup.
Preoperative Lipoprotein(a) and Dose-Dependent Risk of Stroke After Intracranial Stenting for Symptomatic Atherosclerosis: A Retrospective Analysis of a Contemporary Prospective Registry.
Fan Q, Li F, Pu M … +1 more , Zhang G
Neurologist · 2026 May · PMID 42224073 · Publisher ↗
OBJECTIVES: Lipoprotein(a) [Lp(a)] is an established risk factor for atherosclerotic disease and predicts events after coronary or carotid revascularization. Its role after intracranial artery stenting remains undefined....
OBJECTIVES: Lipoprotein(a) [Lp(a)] is an established risk factor for atherosclerotic disease and predicts events after coronary or carotid revascularization. Its role after intracranial artery stenting remains undefined. We investigated the association between preoperative Lp(a) and 1-year stroke risk post-stenting for symptomatic intracranial atherosclerotic stenosis (ICAS), as well as to characterize the dose-response relationship. METHODS: In this retrospective analysis of a prospectively maintained registry, we enrolled consecutive patients undergoing stenting for symptomatic ICAS (2022 to 2024). Patients were categorized by preoperative Lp(a) (<30 vs. ≥30 mg/dL). The primary endpoint was ischemic stroke (30 d to 1 y). Associations were assessed through Kaplan-Meier, Cox regression, and restricted cubic splines (RCS) for dose-response analysis. Sensitivity and competing-risk analyses were performed. RESULTS: Among 405 patients, the high Lp(a) group (n=132) had a significantly higher stroke incidence (12.87% vs. 6.27%, P=0.024). After adjusting for diabetes and follow-up LDL-C, Lp(a) ≥30 mg/dL was independently associated with stroke risk (adjusted HR=2.05, 95% CI: 1.04-4.04; P=0.038). Results were robust in sensitivity analyses. RCS analysis confirmed a significant nonlinear dose-response relationship (P for nonlinearity=0.010). The risk increased progressively across the Lp(a) distribution, with a markedly attenuated slope of increase at concentrations above ~50 mg/dL. A post hoc cutoff of ≥50 mg/dL yielded a higher HR (2.73) but with wider confidence intervals. CONCLUSIONS: In a contemporary ICAS stenting cohort, elevated preoperative Lp(a) is an independent predictor of 1-year stroke recurrence, demonstrating a nonlinear dose-response pattern. The 30 mg/dL threshold is pragmatic for clinical risk screening, whereas the 50 mg/dL level may serve to enrich populations for trials of novel Lp(a)-lowering therapies. These findings require prospective, multicenter validation.
Predictive Value of Unilateral Hand Automatism and Brain Positron Emission Tomography Scan in Temporal Lobe Epilepsy Surgery Outcomes.
Abuhulayqah S, Alshehri K, Asiry M … +1 more , Alqadi K
Neurologist · 2026 May · PMID 42165422 · Full text
OBJECTIVES: This study aimed to identify the lateralizing value of unilateral hand automatism, with or without concomitant contralateral hand dystonic posturing, in mesial temporal lobe epilepsy (MTLE) and to determine s...
OBJECTIVES: This study aimed to identify the lateralizing value of unilateral hand automatism, with or without concomitant contralateral hand dystonic posturing, in mesial temporal lobe epilepsy (MTLE) and to determine surgical outcomes in patients who underwent resection. METHODS: In this retrospective chart review study, we reviewed video recordings of 50 patients who consecutively underwent presurgical evaluations with ictal video-electroencephalogram recordings between 2018 and 2022 and had epilepsy surgery for intractable MTLE. RESULTS: All patients with right-hand automatism without contralateral dystonia (10 patients) had ipsilateral right MTLE, whereas only 50% of patients with right-hand automatism and associated contralateral dystonia (8 patients) did. Sixteen patients had left-hand automatism with contralateral dystonia, of which 68% had ipsilateral left MTLE, whereas only 2 of 6 patients with only left-hand automatism had similar findings. A brain positron emission tomography (PET) scan showed right temporal hypometabolism in 23 patients (46%), whereas 19 patients (38%) had left temporal hypometabolism. 42 (84%) patients had a class I surgical outcome (free of disabling seizures) according to the Engel Classification, a favorable outcome. Lateralization of the PET scan was significantly associated with the best surgical outcome. CONCLUSION: This study showed that unilateral upper-limb automatisms in MTLE occur mostly ipsilaterally to the epileptogenic zone, and that the right hand is more sensitive and specific when automatisms occur. Left upper-limb automatism with contralateral dystonia is associated with a higher likelihood of an ipsilateral left epileptogenic focus. The brain PET scan best predicted surgical outcomes in MTLE.
Comparative Analysis of Endovascular Treatment Outcomes in Acute Large Vessel Occlusion Strokes: Intracranial Atherosclerotic Versus Nonintracranial Atherosclerotic Occlusions.
Mohammadzadeh N, Shu L, Khan F … +8 more , Torabi R, Snow E, Chang K, Moldovan K, Jayaraman M, Goldstein ED, Kala N, Yaghi S
Neurologist · 2026 May · PMID 42133469 · Publisher ↗
OBJECTIVES: Intracranial atherosclerotic disease (ICAD) is a common cause of ischemic stroke worldwide. We assessed the clinical outcomes of endovascular treatment in acute large vessel occlusion (LVO) strokes caused by...
OBJECTIVES: Intracranial atherosclerotic disease (ICAD) is a common cause of ischemic stroke worldwide. We assessed the clinical outcomes of endovascular treatment in acute large vessel occlusion (LVO) strokes caused by ICAD and compared them with large vessel occlusion strokes not associated with intracranial atherosclerosis (non-ICAD LVO). METHODS: We included consecutive adult patients diagnosed with LVO stroke who underwent endovascular therapy at Rhode Island Hospital from July 2015 to March 2023, and data were collected retrospectively. We compared baseline characteristics and outcomes, including recurrent in-hospital large vessel occlusion, disability, and mortality between these 2 groups (ICAD LVO vs. non-ICAD LVO). We used the t test, χ 2 , and Fisher exact tests were used for the comparison of groups and adjusted binary logistic regression to compare outcomes between the 2 groups. RESULTS: Our study comprised 1390 adult patients diagnosed with LVO stroke who underwent endovascular therapy at Rhode Island Hospital from July 2015 to March 2023, and data were collected retrospectively. Among these, 68 patients were ICAD LVO, while 1322 individuals were categorized as non-ICAD LVO. In the ICAD-LVO group, 38 patients received stenting, while 30 did not, of whom 23 underwent angioplasty. Patients with ICAD LVO group had a higher odds of reocclusion during hospitalization (11.8% vs. 4%, P =0.008), but there was no significant difference in good 90-day functional outcome (mRS ≤2) (OR: 0.89; 95% CI: 0.45-1.79; P =0.749) and 90-day mortality rate (OR: 1.47; 95% CI: 0.69-3.14; P =0.320) between the ICAD LVO and non-ICAD LVO groups. CONCLUSIONS: Our study showed increased odds of reocclusion during hospitalization in the ICAD LVO group following endovascular therapy. However, we did not observe any statistically significant differences in measures of disability and mortality between the 2 groups.
Optimizing Levetiracetam Dosage in Status Epilepticus: A Retrospective Cohort Study.
Bendock EL, Medenwald BL, Starnes CJ … +5 more , Rowe AS, Christianson TJ, Farley KH, Minton KR, Hamilton LA
Neurologist · 2026 May · PMID 42132540 · Publisher ↗
OBJECTIVES: Status epilepticus (SE) is a severe neurological condition with significant morbidity and mortality. While guidelines offer recommendations for emergent therapy with benzodiazepines, there is limited guidance...
OBJECTIVES: Status epilepticus (SE) is a severe neurological condition with significant morbidity and mortality. While guidelines offer recommendations for emergent therapy with benzodiazepines, there is limited guidance for medications for urgent control in SE. High-dose levetiracetam (LEV) (60 mg/kg) was introduced in the 2019 ESETT trial and has not been studied against the previous standard. METHODS: This retrospective cohort evaluated patients admitted for SE. Patients were included if they received ≥1 dose of intravenous LEV ≥20 mg/kg from January 1, 2019, to January 14, 2022, and were 17 years of age or older. Traumatic injuries were excluded. Patients were divided into groups of LEV loading dose of <40 mg/kg and LEV loading dose of ≥40 mg/kg. RESULTS: Patients who received ≥40 mg/kg of LEV were less likely to require a second ASM within 48 hours as compared with those receiving <40 mg/kg [39(69.9%) vs. 15(38.5%); P=0.0127]. After logistic regression analysis that included home ASM use, doses ≥40 mg/kg of LEV, and a total of ≥4 mg of lorazepam equivalents received, no difference was seen in ASM requirements. Patients who received <40 mg/kg were more likely to have a history of seizure and be on ASMs before admission. CONCLUSIONS: After logistic regression, the loading dose of LEV did not change the need for additional ASM to control seizures in SE. Further investigations evaluating the efficacy of 20 mg/kg compared with 60 mg/kg are needed; however, this study found no difference in seizure control between the groups.
Risk Factors of Carotid Intraplaque Neovascularization Detected By Contrast-Enhanced Ultrasound.
Fu W, Wang Y, Wang Q … +5 more , Bi Q, Qin Y, Xu W, Zhang Q, Wang F
Neurologist · 2026 Mar · PMID 42132520 · Publisher ↗
OBJECTIVES: To evaluate the potential risk factors of intraplaque neovascularization (IPN) detected by contrast-enhanced ultrasound (CEUS). METHODS: From June 2018 to June 2022, patients who underwent CEUS in 2 centers w...
OBJECTIVES: To evaluate the potential risk factors of intraplaque neovascularization (IPN) detected by contrast-enhanced ultrasound (CEUS). METHODS: From June 2018 to June 2022, patients who underwent CEUS in 2 centers were enrolled. Demographics, comorbidities, serum index, blood cell classification, lipids, the classification of IPN and follow-up information were collected and analyzed. The classification of IPN was identified on the basis of microbubbles within the plaque and graded as: grade 1=no appearance of bubbles within the plaque; grade 2=moderate appearance of bubbles within the plaque; and grade 3=extensive appearance of bubbles within the plaque. Univariate and multivariate logistic regression analysis were used to identify potential independent risk factors of IPN. RESULTS: A total of 91 patients were enrolled and analyzed. The mean age was 66.3±9.45 (ranged: 35 to 92 y). The IPN were detected in 50 (54.9%) patients. Compared with patients without IPN, patients with that were more likely to have diabetes mellitus (DM) (P<0.001), hyperlipidemia (P=0.016), and higher serum hs-CRP level (P<0.001). The level of LDL-C ≥100 mg/dL was detected in more patients with IPN (P<0.001), and more patients with IPN had a history of alcohol drinking (P=0.046) and coronary artery disease (CAD) (P=0.08). Meanwhile, patients with IPN showed significantly higher neutrophil/lymphocyte ratio (NLR) (3.2±1.4 vs. 2.0±1.2, P<0.001), the plaque thickness was higher in patients with IPN compared with patients without that (2.5±1.0 vs. 1.8±1.0 mm, P=0.003). In the multivariate analysis, DM [odds ratio (OR): 0.042; 95% CI: 0.004-0.441; P=0.008], hs-CRP >2 mg/L (OR: 0.124; 95% CI: 0.016-0.978; P=0.048), and LDL-C ≥100 mg/dL (OR: 0.10; 95% CI: 0.001-0.153; P=0.001) were independent risk factors of IPN. CONCLUSIONS: IPN was not rare in patients with carotid plaque, and CEUS was effective in detecting IPN in clinical practice. DM, hs-CRP >2 mg/L, and LDL-C ≥100 mg/dL were independent risk factors of IPN.
From Eight-and-a-Half to Nine: A Case Report Highlighting an Uncommon Brainstem Syndrome.
Pitton Rissardo J, Byroju VV, Gribachov A … +3 more , Fornari Caprara AL, Thon OR, Ballout A
Neurologist · 2026 May · PMID 42132519 · Publisher ↗
INTRODUCTION: Nine syndrome is a rare clinical brainstem syndrome combining one-and-a-half syndrome with ipsilateral facial weakness and long-tract signs such as contralateral hemiparesis or hemiataxia. It typically resu...
INTRODUCTION: Nine syndrome is a rare clinical brainstem syndrome combining one-and-a-half syndrome with ipsilateral facial weakness and long-tract signs such as contralateral hemiparesis or hemiataxia. It typically results from pontine tegmentum lesions, most often due to acute ischemic stroke. We conducted a systematic review of published cases using PubMed, Scopus, and Web of Science (search until October 2025). Data on demographics, clinical features, imaging, etiology, and outcomes were summarized descriptively. CASE REPORT: A 73-year-old woman with vascular risk factors presented with diplopia, ipsilateral facial weakness, and contralateral arm weakness, consistent with nine syndrome. MRI revealed infarction in the left dorsal pons and ventral medulla. Stroke etiology was attributed to small-vessel ischemic disease. She was started on dual antiplatelet as well as aggressive risk factor management. At 4-month follow-up, her motor symptoms had largely improved, albeit with residual diplopia. Literature review identified 25 cases with similar presentation (mean age 57.7 years; 66.7% male). Contralateral hemiparesis occurred in 52%, hemiataxia in 24%, and sensory deficits in 32%. Ischemic stroke was the leading cause (68%), followed by hemorrhagic stroke (20%) and demyelinating conditions (12%). Complete recovery was rare (4%), with most cases showing partial improvement. CONCLUSION: Nine syndrome reflects a strategically located pontine lesion disrupting multiple adjacent structures. Ischemic stroke predominates, highlighting the need for early MRI and vascular imaging. Recognition of this rare syndrome aids accurate diagnosis and targeted management.
The "Paradoxical Dilation" Sign as an Indicator for Overlooked Collateral Arterial Supply in Chronic Subdural Hematoma.
Li M, Niu Y, Jiang Z … +2 more , Li W, Chen Z
Neurologist · 2026 May · PMID 41931664 · Publisher ↗
INTRODUCTION: Middle meningeal artery embolization (MMAE) is a safe and effective established treatment for chronic subdural hematoma (CSDH). However, treatment failures and recurrences remain a concern, with underlying...
INTRODUCTION: Middle meningeal artery embolization (MMAE) is a safe and effective established treatment for chronic subdural hematoma (CSDH). However, treatment failures and recurrences remain a concern, with underlying causes still unclear. Collateral arterial supply, while sporadically reported, have not yet been attached full importance. CASE REPORT: A 60-year-old male presenting with left CSDH exhibited a marked morphologic asymmetry of middle meningeal artery (MMA) on 7T time-of-flight MR angiography (TOF-MRA), with notably right MMA dilation. Digital subtraction angiography (DSA) confirmed this paradoxically dilated right MMA as the primary arterial supply to the hematoma membrane. Subsequent bilateral MMA embolization resulted in immediate symptom resolution and near-complete hematoma regression at 1-month follow-up. CONCLUSION: "Paradoxical dilation" sign might indicate overlooked collateral arterial supply in CSDH, necessitating systematic vascular evaluation to achieve the "hematoma membrane supply embolization" over unilateral MMA embolization. Noninvasive imaging such as TOF-MRA could facilitate preoperative detection of this collateral arterial supply.
Timing of Initiation of Pharmacologic Venous Thromboembolism Prophylaxis in Patients With Intracerebral Hemorrhage.
Ayesh W, Houry E, Hodges G
Neurologist · 2026 May · PMID 41931660 · Publisher ↗
OBJECTIVE: Optimal timing of initiation of pharmacologic venous thromboembolism (VTE) prophylaxis following intracerebral hemorrhage is controversial. This study aims to assess the association between the timing of pharm...
OBJECTIVE: Optimal timing of initiation of pharmacologic venous thromboembolism (VTE) prophylaxis following intracerebral hemorrhage is controversial. This study aims to assess the association between the timing of pharmacologic VTE prophylaxis initiation and the risk of VTE and hemorrhagic complications. METHODS: This was a multicenter, retrospective cohort study completed at 7 community hospitals. This study included patients with nontraumatic intracerebral hemorrhage admitted from August 1, 2023, to July 31, 2024. A total of 111 patients were assessed and categorized based on the administration of early (≤48 h) versus delayed (>48 h) initiation of VTE prophylaxis. RESULTS: Findings showed no statistically significant difference in the primary outcome of the incidence of VTE with early versus delayed initiation of VTE prophylaxis (5% vs. 8%, P =0.713). Secondary outcomes included incidence of deep vein thrombosis (5% vs. 8%, P =0.713), pulmonary embolism (0% vs. 0%), hematoma enlargement (16% vs. 15%, P =0.623), median intensive care unit (ICU) length of stay (3 vs. 3.5 d, P =0.670), hospital length of stay (7 vs. 8 d, P =0.724), inpatient all-cause mortality (8% vs. 7%, P =1.000), and discharge disposition. CONCLUSION: Early pharmacologic VTE prophylaxis (≤48 h from ICH onset) was not found to be statistically significant in lowering the incidence of VTE. This occurred with no statistically significant differences in hematoma enlargement, increased inpatient mortality, or increased length of ICU/hospital stay. Additional adequately powered studies are needed to determine if early pharmacologic VTE prophylaxis is associated with a lower incidence of VTE.
Kimura's Disease Complicated by Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy: A Case Report and Review of the Literature.
Wu Y, You X, Qiu J
Neurologist · 2026 May · PMID 41925165 · Full text
INTRODUCTION: Kimura's disease is a chronic inflammatory disorder, while cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited cerebral small vessel disease....
INTRODUCTION: Kimura's disease is a chronic inflammatory disorder, while cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited cerebral small vessel disease. CASE REPORT: A 56-year-old Chinese male with a 6-year history of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy was admitted due to recurrent cerebral infarcts. He also had a concurrent diagnosis of Kimura's disease accompanied by hypereosinophilia and elevated serum immunoglobulin E levels. Although the patient had been on oral antiplatelet therapy, no preventive treatment had been previously administered for the hypereosinophilia or high immunoglobulin E levels. We conducted follow-up to track disease progression and to review the management approach, including its strengths and shortcomings. CONCLUSION: This case represents a rarely reported instance of Kimura's disease coexisting with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. It underscores the importance of differentiating stroke etiologies and illustrates the potential for complications when hypereosinophilic conditions are left untreated.
Prediction of Malignant Brain Edema Based on Contrast Agent Exudation After Mechanical Thrombectomy for Anterior Circulation Occlusion.
Bi Y, Wang S, Mu Rong Y … +7 more , Wei M, Jiang N, Ding Y, Liao H, Liu X, Zeng X, Chen YB
Neurologist · 2026 May · PMID 41925029 · Full text
OBJECTIVE: Malignant brain edema (MBE) after mechanical thrombectomy (MT) for anterior circulation occlusion leads to poor outcomes. Although contrast agent extravasation (CAE) indicates blood-brain barrier disruption, i...
OBJECTIVE: Malignant brain edema (MBE) after mechanical thrombectomy (MT) for anterior circulation occlusion leads to poor outcomes. Although contrast agent extravasation (CAE) indicates blood-brain barrier disruption, its predictive value for MBE remains uncertain. This study evaluated whether the CAE-Alberta Stroke Program Early CT Score (CAE-ASPECTS) derived from dual-source computed tomography (CT) could predict MBE after anterior circulation recanalization with MT. METHODS: Patients with anterior circulation occlusion undergoing mechanical thrombectomy (MT) were divided into malignant brain edema (MBE) and non-MBE groups. The primary outcome was to determine whether postoperative CAE-ASPECTS scores predicted MBE. The secondary outcomes were to identify factors influencing malignant brain edema and to examine the association between CAE-ASPECTS and 90-day modified Rankin Scale (mRS) and 72-hour intracerebral hemorrhage. RESULTS: The MBE group had a significantly lower median postoperative CAE-ASPECT score. After adjusting for confounding factors, CAE-ASPECTS remained independently associated with MBE. Lower CAE-ASPECTS, higher National Institutes of Health Stroke Scale (NIHSS) score, and longer operative time were associated with increased MBE risk. The regression model yielded a predictive accuracy of 93%. Favorable 90-day mRS (0 to 2) was more common in the non-MBE group, and mortality was lower. Finally, cerebral hemorrhagic transformation was inversely correlated with CAE-ASPECTS. CONCLUSION: Lower CAE-ASPECTS scores were significantly correlated with increased MBE incidence. Moreover, CAE-ASPECTS was an independent predictor of MBE, while cerebral hemorrhage transformation was negatively correlated with the CAE-ASPECTS after successful thrombectomy. Finally, CAE-ASPECTS, preoperative NIHSS, ASPECTS, and operative time collectively predict MBE with 93% sensitivity, providing a useful imaging biomarker for post-MT risk assessment.
Convexity Subarachnoid Hemorrhage Due to Large Artery Atherosclerotic Stenosis or Occlusion: A Report of 3 Cases.
Li C, Mu S, Tao T
Neurologist · 2026 May · PMID 41912455 · Publisher ↗
INTRODUCTION: Convexity subarachnoid hemorrhage (cSAH) is a rare subtype of nontraumatic subarachnoid hemorrhage. Large artery atherosclerotic stenosis or occlusion has emerged as a prevalent etiology in China. The diagn...
INTRODUCTION: Convexity subarachnoid hemorrhage (cSAH) is a rare subtype of nontraumatic subarachnoid hemorrhage. Large artery atherosclerotic stenosis or occlusion has emerged as a prevalent etiology in China. The diagnosis of cSAH is primarily based on imaging examinations. However, there are no established guidelines or consensus for its treatment. CASE REPORT: This report presented 3 cases of cSAH associated with atherosclerotic stenosis or occlusion. All 3 patients had significant large-artery stenosis or occlusion. In 2 cases (cases 1 and 3), computed tomography (CT) angiography revealed stenosis of the right middle cerebral artery and internal carotid artery, while the third case (case 2) exhibited bilateral internal carotid and middle cerebral artery stenosis. Two patients (cases 1 and 2) were treated with antiplatelet therapy under close monitoring of vital signs and serial CT scans, resulting in significant symptom improvement and no evidence of rebleeding on the follow-up CT scan. The other patient (case 3), who underwent balloon angioplasty of the right internal carotid artery, experienced symptom worsening, including brain herniation and poor prognosis. CONCLUSION: This report summarized the clinical presentations, imaging findings, etiology, treatments, and prognoses of 3 cSAH cases, which may provide a reference for the standardized diagnosis and management of such patients.
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