Unusual presentation of basilar artery stroke secondary to patent foramen ovale: a case report

<p>Abstract</p> <p>Introduction</p> <p>We report a case of a patient presenting with neuropsychiatric manifestations secondary to paradoxical embolism</p> <p>Case presentation</p> <p>Unexplained rapid onset of confusion with amnesia and minimal neurological deficits can be a manifestation of various systemic causes of which stroke, either ischemic or hemorrhagic, is one. Thorough and systematic evaluation of these patients can be highly rewarding in terms of optimizing patient outcome. We report the case of a 45-year-old woman whose initial presentation was with acute onset of confusion, memory loss with personality change and headaches. A differential diagnosis of systemic illness and cerebral pathology was entertained. She was empirically treated for neurological infection. Brain imaging revealed bilateral thalamic and cerebellar infarction. Further evaluation with an aim to define the etiology, revealed the diagnosis of Patent Foramen Ovale with paradoxical embolism. The differential diagnosis of unexplained rapid onset of confusion, amnesia with minimal motor neurological deficits and relevant appropriate investigations are discussed in this case report.</p> <p>Conclusion</p> <p>This case highlights the importance of recognising the atypical manifestations of posterior fossa stroke. In young patients presenting with non-focal neuropsychiatric manifestations, paradoxical embolism, secondary to patent foramen ovale is a possible cause.</p

Relapse patterns in NMOSD: evidence for earlier occurrence of optic neuritis and possible seasonal variation

Neuromyelitis optica spectrum disorders (NMOSD) and multiple sclerosis (MS) show overlap in their clinical features. We performed an analysis of relapses with the aim of determining differences between the two conditions. Cases of NMOSD and age- and sex-matched MS controls were collected from across Australia and New Zealand. Demographic and clinical information, including relapse histories, were recorded using a standard questionnaire. There were 75 cases of NMOSD and 101 MS controls. There were 328 relapses in the NMOSD cases and 375 in MS controls. Spinal cord and optic neuritis attacks were the most common relapses in both NMOSD and MS. Optic neuritis (p P = 0.002) were more common in NMOSD and other brainstem attacks were more common in MS (p P = 0.065). Optic neuritis and transverse myelitis are the most common types of relapse in NMOSD and MS. Optic neuritis tends to occur more frequently in NMOSD prior to the age of 30, with transverse myelitis being more common thereafter. Relapses in NMOSD were more severe. A seasonal bias for relapses in spring-summer may exist in NMOSD

Can\u27t Hold Me Back! Constraint-Induced Movement Therapy for Children with CP: Evidence Based Review

Children with cerebral palsy (CP) have various functional impairments impacting participation in meaningful occupations. While Constraint-Induced Movement Therapy (CIMT) is a widely used intervention for adult populations, a modified version of this technique is a relatively new practice in pediatrics (Charles et al., 2006). Occupational therapy intervention, such as CIMT, can support functional goal attainment to enhance participation and quality of life (Boyd et al., 2010). The purpose of this presentation is to synthesize results of a comprehensive evidence-based review and identify treatment characteristics that impact efficacious use of mCIMT on children with hemiplegic CP. Practitioners will learn about best practice strategies according to current literature. After formulation of a clinical research question, a systematic search of 3 databases was conducted, yielding 15 articles. A rigorous screening process was used with specific inclusion and exclusion criteria. These articles were critiqued to identify the effectiveness of mCIMT. Using Law and MacDermid’s (2008) Appendix M, each article was reviewed by a primary rater with input from a secondary rater. Findings were synthesized and will be discussed in this presentation. The literature review indicated overall positive results for the use of mCIMT with pediatric CP populations. The majority of studies have found statistically significant results, however, there are mixed conclusions regarding clinical effect. A variety of protocol durations and types of constraints have been investigated, and demonstrate that a minimum of 1-2 hours of constraint wear time for 10-14 consecutive days may be effective in a clinic or home environment. Evidence suggests that the most effective mCIMT protocol involves a child-friendly approach using functional and age-appropriate tasks. Both preparatory and occupation-based activities were assessed utilizing a variety of standardized outcome measures. This presentation impacts clinical practice by providing evidence about the most effective intervention characteristics for implementing mCIMT as a useful and feasible treatment approach. Overall, children who received mCIMT by a trained interventionist improved functionally regardless of the protocol. Findings suggest less restrictive methods may be comparable to more intensive mCIMT interventions. Therefore, interventionists can tailor a specific mCIMT approach to meet the unique needs of each child. References: Boyd, R., Sakzewski, L., Ziviani, J., Abbott, D. F., Badawy, R., Gilmore, R., . . . Jackson, G. D. (2010). INCITE: A randomised trial comparing constraint induced movement therapy and bimanual training in children with congenital hemiplegia. BMC Neurology, 10, 1-15. doi:10.1186/1471-2377-10-4 Charles, J. R., Wolf, S. L., Schneider, J. A., & Gordon, A. M. (2006). Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: A randomized control trial. Developmental Medicine and Child Neurology, 48(8), 635-642. doi:10.1017/S0012162206001356 Law, M. & MacDermid, J. (2008). Appendix M: Effectiveness Study Quality Checklist. In Evidence-based rehabilitation: A guide to practice (413-423). Thorofare, NJ: Slack, Inc

CORTICAL EXCITABILITY AND REFRACTORY EPILEPSY: A THREE-YEAR LONGITUDINAL TRANSCRANIAL MAGNETIC STIMULATION STUDY

Fulltext embargoed for: 18 months post date of publicationTranscranial magnetic stimulation was used to study the effect of recurrent seizures on cortical excitability over time in epilepsy. 77 patients with firm diagnoses of idiopathic generalized epilepsy (IGE) or focal epilepsy were repeatedly evaluated over three years. At onset, all groups had increased cortical excitability. At the end of follow-up the refractory group was associated with a broad increase in cortical excitability. Conversely, cortical excitability decreased in all seizure free groups after introduction of an effective medication

Prevalence of depression and use of antidepressant medication at 5 years post stroke in the North East Melbourne Stroke Incidence Study (NEMESIS)

BACKGROUND AND PURPOSE - There are few data on the prevalence or treatment of depression from unselected populations long-term poststroke. We assessed the prevalence of depression and antidepressant use at 5-years poststroke in an unselected stroke population. METHODS - Five-year survivors from a prospective community-based stroke incidence study were assessed for depression with the Irritability, Depression and Anxiety Scale. Medications indicated primarily for treatment of depression were recorded. RESULTS - At 5-years poststroke, 441 (45%) of 978 incident cases were alive (mean age=74±15 years, 49% female). Seventeen percent of those assessed were depressed. Twenty-two percent with depression were taking an antidepressant medication. Of those taking an antidepressant, 72% were not depressed. CONCLUSIONS - Although nearly one-fifth of survivors were depressed, few were taking antidepressants. Further exploration of this low level of treatment is warranted. © 2006 American Heart Association, Inc

Handicap 5 years after Stroke in the North East Melbourne Stroke Incidence Study

Background: Handicap is rarely comprehensively examined after stroke. We examined handicap among 5-year stroke survivors from an ‘ideal’ stroke incidence study. Methods: Survivors were assessed with the London Handicap Scale (LHS, score range: 0 [greatest handicap] to 100 [least handicap]). Multivariable regression was used to examine demographic, risk factor and stroke-related factors associated with handicap. Results: 351 of 441 (80%) survivors were assessed. Those assessed were more often Australian born than those not assessed (p<0.05). The mean LHS score was 73 (SD 21). The greatest handicap was present for physical independence and occupation/leisure items. Handicap was associated with older age, manual occupations, smoking, initial stroke severity, recurrent stroke and mood disorders. Conclusion: Reducing recurrent stroke, through better risk factor management, is likely to reduce handicap. The association between handicap and mood disorders, which are potentially modifiable, warrants further investigation. Handicap, more recently known as ‘participation restriction’, refers to an individual’s ability to participate in everyday life situations. The London Handicap Scale (LHS) is one of few instruments designed to assess handicap according to the World Health Organization (WHO) definition [1] and has been validated for use in stroke patients.[2] The LHS was developed using the superseded WHO definition of handicap; however, others have demonstrated that it accurately measures the new WHO definition of participation restriction.[1] Studies of handicap in which investigators have used measures somewhat consistent with the WHO definition are limited.[3-10] Of these studies, only two incorporated a measure of handicap beyond 2 years post stroke,[9, 10] and only one comprised an unselected population of stroke survivors.[9] We aimed to (1) establish the pattern and level of handicap at 5 years post stroke; and (2) identify factors that are associated with handicap in 5-year stroke survivors

Factors associated with quality of life in 7-year survivors of stroke

Background Little is known about health-related quality of life (HRQoL) in the long term after stroke. Aim The aim of this study was to assess the level of, and factors associated with, HRQoL at 7 years post-stroke. Methods All stroke cases from a prospective community-based stroke incidence study (excluding subarachnoid haemorrhage) were assessed 7 years after stroke. HRQoL was measured with the Assessment of Quality of Life instrument. Proportional odds ordinal logistic regression was used to determine factors associated with HRQoL at 7 years post-stroke. Results Overall, 1321 stroke cases were recruited. Seven years after stroke, 413 (31.2%) were alive and 328 (79.4%) were assessed. Those assessed were less often current smokers pre-stroke than those not assessed (p<0.01). Seventy-six survivors (23%) had very poor HRQoL (range: -0.038 to 0.100). Factors present at 7 years that were associated with better 7-year HRQoL were independence in instrumental activities of daily living (IADL) (estimated OR=11.2, 95% CI 4.87 to 25.6, p<0.001), independence in basic activities of daily living (BADL) (OR=4.53, 95% CI 2.03 to 10.1, p<0.001), independence in IADL and BADL (OR=9.90, 95% CI 4.51 to 21.7, p<0.001), male gender (OR=1.89, 95% CI 1.21 to 2.96, p=0.005) and lesser handicap (trend: OR=3.47, 95% CI 2.51 to 4.79, p<0.001). Participants' HRQoL scores tended to be lower when HRQoL assessments were completed by proxy (OR=0.13, 95% CI 0.06 to 0.31, p<0.001). Conclusion At 7 years post-stroke, 68.8% had died and a substantial proportion of survivors had poor HRQoL. Factors such as handicap, BADL and IADL could be targeted to improve HRQoL in long-term survivors of stroke