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Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal syndrome classically encountered in patients receiving typical antipsychotic agents. However, many physicians have also reported the occurrence of NMS with atypical antipsychotics, notably with atypical presentations. In this report, we present a case in which a patient's antipsychotic regimen during a psychotic episode (which involved both typical and atypical antipsychotics) subsequently led to NMS. During his stay, the patient developed an altered level of consciousness, elevation of creatine phosphokinase, hemodynamic instability, and a fever. However, the patient did not have signs of rigidity, the cardinal sign of this syndrome. The authors concluded that patients could develop NMS without rigidity while receiving an antipsychotic. Given this presentation, the authors suggest that clinicians have a high level of suspicion for NMS to avoid misdiagnosis and subsequent adverse consequences. Hence, clinicians must be vigilant about atypical presentations of NMS without rigidity.

Objectives: Adverse effects of intracoronary injection of stem cells on in-stent restenosis and atherosclerotic progression remain unclear. We sought to evaluate the adverse effects of intracoronary injection of CD133 cells on in-stent restenosis and atherosclerotic progression in the infarct-related and contralateral arteries using serial intravascular ultrasound (IVUS) analysis., Methods: Baseline and 4-month follow-up IVUS images were obtained from 17 patients treated with intracoronary stem cell injection and 20 placebo patients after primary percutaneous coronary intervention in the COMPARE-AMI trial. In the infarct-related artery, the stented segment, 5 mm proximal and distal reference segments, and proximal and distal nonstented segments were analyzed every 1 mm; the entire segment of a contralateral artery was also analyzed every 1 mm., Results: In the infarct-related artery analysis, the median percentage of in-stent neointimal hyperplasia (12.1 vs. 7.6%, P=0.95), the reduction in the minimum lumen area (MLA; -1.6 vs. -1.5 mm(2), P=0.97), and the MLA at follow-up (4.3 vs. 5.3 mm(2), P=0.21) were found to be similar between the stem cell and placebo groups. Changes in proximal and distal nonstented segment lumen areas and plaque burden were also similar between the stem cell and placebo groups; however, there was a decrease in the maximum arc of the attenuated plaque behind the stent from baseline to follow-up in the placebo group (P=0.004), but not in the stem cell group. In the contralateral artery, there were no differences in changes in MLA, plaque burden, or attenuated plaque between stem cell and placebo patients., Conclusion: Intracoronary injection of CD133(+) bone marrow stem cells has no IVUS-detectable effect on neointimal hyperplasia or atherosclerosis progression in either infarct-related or contralateral arteries.

Background and Purpose: Despite clear roles of factor VIII (FVIII) and von Willebrand factor (vWF) in thrombosis, few studies have examined the relationship of these factors with acute ischemic stroke (AIS). We sought to determine whether concurrent elevation in FVIII and vWF was associated with adverse events and outcomes., Methods: From our prospective stroke registry, patients consecutively admitted with AIS between July 2008 and October 2013 were included if both FVIII and vWF were measured during admission. The primary outcome was the modified Rankin Scale score on discharge., Results: Among 1453 cases in our stroke registry, 148 patients with AIS met inclusion criteria; 62 patients (41.9%) had FVIII-/vWF-, 16 patients (10.8%) had FVIII+/vWF-, and 51 patients (34.5%) had FVIII+/vWF+. In the fully adjusted model, patients with FVIII+/vWF+ had increased odds of inpatient complications (odds ratio, 8.6; 95% confidence interval, 1.58-46.85; P=0.013) and neuroworsening (odds ratio, 3.2; 95% confidence interval, 1.18-8.73; P=0.022) than patients with FVIII-/vWF-. Adjusted for age, baseline stroke severity, and glucose, patients with FVIII+/vWF+ had increased odds of poor functional outcome (modified Rankin Scale>2; odds ratio, 2.87; 95% confidence interval, 1.16-7.06; P=0.021) than patients with FVIII-/vWF-., Conclusions: Concurrent FVIII/vWF elevation predicts higher odds of inpatient complications, neuroworsening, and worse functional outcomes for patients with AIS compared with patients with normal levels. Our findings suggest that FVIII and vWF levels may serve as clinically useful stroke biomarkers by providing risk profiles for patients with AIS., (© 2014 American Heart Association, Inc.)

Background: Despite recent advances in acute stroke therapy, only a small proportion of patients with acute ischemic stroke receive IV and endovascular revascularization therapies. This article provides an overview of factors influencing access to stroke therapy., Methods: The key factors influencing access to stroke care highlighted during the Society of Vascular and Interventional Neurology (SVIN) roundtable meeting are summarized. Pertinent selected references on prehospital, hospital, and legislative and economic factors influencing access to stroke care, from the Medline database (between 1995 to 2011), are included. A brief summary of these key factors in improving access to stroke therapy is provided., Results: Prehospital factors include the community; education of hospital administrators and health care personnel; dispatchers; the medical transport system; and preparedness and stroke education of emergency medical services (EMS). Stroke-ready hospitals and networking with other regional tertiary stroke hospitals play important roles in increasing access to stroke care. In addition, legislation at the state and federal levels is a key factor in providing high-quality, timely access to stroke care for the population in general. Strategies to facilitate access to stroke therapy are critical to improving mortality and functional outcome and increasing the proportion of patients treated by systemic thrombolysis and endovascular approaches., Conclusion: This is a brief overview and summary of selected factors influencing access to stroke care. These factors are divided into prehospital, hospital, legislative, and economic categories. Multilevel education of the population, public health care personnel, hospital preparedness, and legislative and economic factors are important in improving access to stroke care.