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Introduction To present a case of basilar thrombosis with lessons for improving care. Methods Case presentation Results 89 year old Female with history of coronary artery disease with prior stenting brought in by ambulance for cardiac arrest. Patient last known normal 0900 per son. At 1100 patient called EMS for sudden onset nausea with projectile emesis. On arrival EMS staff noted patient to be walking and talking and administered zofran. After eight to ten minutes staff witnessed patient undergo cardiopulmonary arrest and initiated cardiac compressions. Return of spontaneous cardiac activity achieved after one dose of epinephrine and two minutes of compressions. In emergency department at 1132 patient moving extremities and following commands but intubated for encephalopathy and hypoxia. Computed Tomography (CT) head without contrast performed at 1222 showed hypodensity in left occipital lobe and left cerebellum suspicious for infarct. Neurology consulted routinely and National Institute of Health Stroke Scale (NIHSS) 21. Stat CT angiography of head and neck completed at 1657 and showed complete occlusion of basilar artery from origin to terminus. Patient evaluated by neurology fellow and found to be unresponsive with decerebrate posturing, NIHSS maximal; Neurosurgery service was paged at 1659 for stat evaluation. Patient arrived at cath lab at 1949 and thrombectomy performed with TICI 2b. Magnetic Resonance Imaging of brain performed next day at 432 showed diffuse diffusion restriction and T2 signal in bilateral occipital lobes, temporal lobes and thalami, throughout midbrain and pons consistent with acute/subacute infarct. Patient was transitioned to comfort care and extubated. Conclusions Acute basilar occlusion is recognized as a potentially treatable condition if diagnosed quickly. Outcomes of these infarcts remain poor but recent evidence from ATTENTION and BOAChE studies has shown that treatment by emergent thrombectomy provides for better outcomes than medical management alone despite higher risk of intracranial hemorrhage and that these benefits can be seen after 12 to 24 hours from symptom onset(1,2). This particular case is unique not only due to the rarity of stroke presenting as intractable emesis but also in its illustration of diagnostic pitfalls of posterior circulation (3,4). In order to provide appropriate treatment, recognition of abnormal presentation of basilar thrombosis becomes increasingly important. Paul et al identified isolated vertigo, vertigo with non‐focal symptoms, isolated double vision, transient generalized weakness, and binocular visual disturbance as significant transient symptoms preceding basilar occlusion (5). Savitz and Caplan report, “most common signs are limb weakness, gait and limb ataxia, oculomotor palsies, and oropharyngeal dysfunction” but also note that vomiting, vertigo, visual loss, numbness can also occur (6). Additionally this patient initial CT scan showed possible stroke but did not identify vessel occlusion. Developments in artificial intelligence are working towards identifying large vessel occlusion on plain noncontrast CT which would have benefitted this patient.

Background In patients with acute ischemic stroke and atrial fibrillation, early anticoagulation prevents ischemic recurrence but with the risk of hemorrhagic transformation (HT). The aims of this study were to evaluate in consecutive patients with acute stroke and atrial fibrillation (1) the incidence of early HT, (2) the time to initiation of anticoagulation in patients with HT, (3) the association of HT with ischemic recurrences, and (4) the association of HT with clinical outcome at 90 days. Methods and Results HT was diagnosed by a second brain computed tomographic scan performed 24 to 72 hours after stroke onset. The incidence of ischemic recurrences as well as mortality or disability (modified Rankin Scale scores >2) were evaluated at 90 days. Ischemic recurrences were the composite of ischemic stroke, transient ischemic attack, or systemic embolism. Among the 2183 patients included in the study, 241 (11.0%) had HT. Patients with and without HT initiated anticoagulant therapy after a mean 23.3 and 11.6 days, respectively, from index stroke. At 90 days, 4.6% (95% confidence interval, 2.3–8.0) of the patients with HT had ischemic recurrences compared with 4.9% (95% confidence interval, 4.0–6.0) of those without HT; 53.1% of patients with HT were deceased or disabled compared with 35.8% of those without HT. On multivariable analysis, HT was associated with mortality or disability (odds ratio, 1.71; 95% confidence interval, 1.24–2.35). Conclusions In patients with HT, anticoagulation was initiated about 12 days later than patients without HT. This delay was not associated with increased detection of ischemic recurrence. HT was associated with increased mortality or disability.

BackgroundThe optimal timing to administer non–vitamin K oral anticoagulants (NOACs) in patients with acute ischemic stroke and atrial fibrillation is unclear. This prospective observational multicenter study evaluated the rates of early recurrence and major bleeding (within 90 days) and their timing in patients with acute ischemic stroke and atrial fibrillation who received NOACs for secondary prevention. Methods and ResultsRecurrence was defined as the composite of ischemic stroke, transient ischemic attack, and symptomatic systemic embolism, and major bleeding was defined as symptomatic cerebral and major extracranial bleeding. For the analysis, 1127 patients were eligible: 381 (33.8%) were treated with dabigatran, 366 (32.5%) with rivaroxaban, and 380 (33.7%) with apixaban. Patients who received dabigatran were younger and had lower admission National Institutes of Health Stroke Scale score and less commonly had a CHA2DS2‐VASc score >4 and less reduced renal function. Thirty‐two patients (2.8%) had early recurrence, and 27 (2.4%) had major bleeding. The rates of early recurrence and major bleeding were, respectively, 1.8% and 0.5% in patients receiving dabigatran, 1.6% and 2.5% in those receiving rivaroxaban, and 4.0% and 2.9% in those receiving apixaban. Patients who initiated NOACs within 2 days after acute stroke had a composite rate of recurrence and major bleeding of 12.4%; composite rates were 2.1% for those who initiated NOACs between 3 and 14 days and 9.1% for those who initiated >14 days after acute stroke. ConclusionsIn patients with acute ischemic stroke and atrial fibrillation, treatment with NOACs was associated with a combined 5% rate of ischemic embolic recurrence and severe bleeding within 90 days.

ObjectiveTonic-clonic activity (TCA) at onset complicates 3% to 21% of cases of subarachnoid hemorrhage (SAH). The impact of onset TCA on in-hospital complications, including seizures, remains unclear. One study associated onset TCA with poor clinical outcome at 6 weeks after SAH, but to our knowledge no other studies have confirmed this relationship. This study aims to assess the impact of onset TCA on in-hospital complications, poor functional outcome, mortality, and epilepsy at 3 months.MethodsAnalysis of a prospective study cohort of 1479 SAH patients admitted to Columbia University Medical Center between 1996 and 2012. TCA within 6 hours of hemorrhage onset was identified based on accounts of emergency care providers or family witnesses.ResultsTCA at onset was described in 170 patients (11%). Patients with onset TCA were younger (P = 0.002), presented more often with poor clinical grade (55% vs. 26%, PConclusionsOnset TCA is not a rare event as it complicates 11% of cases of SAH. New and clinically relevant findings are the association of onset TCA with in-hospital seizures, pneumonia and delayed cerebral ischemia. Despite the increased risk of in-hospital complications, onset TCA is not associated with disability, mortality, and epilepsy at 3 months.

In the medical literature, there have been few reported cases of classic Polyarteritis Nodosa (cPAN) presenting with acute renal failure (ARF) and, unlike microscopic polyangiitis (MPA), no documentation to our knowledge of cPAN with clinical presentation similar to acute interstitial nephritis. We describe a case of ARF and a clinical picture suggestive of acute interstitial nephritis (AIN). However, renal biopsy of this patient showed acute necrotizing intrarenal vasculitis, suggestive of cPAN. Although no guidelines exist for the most appropriate therapy for patients presenting in this fashion, combination therapy with cyclophosphamide and steroids, in our patient, resulted in clinical improvement and resolution of dialysis-dependent renal failure. These findings suggest the potential for good prognosis in patients with cPAN who present with a presumed diagnosis of AIN and dialysis-dependent ARF.