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COVID-19 was initially described as a pulmonary disease. Increasing attention is now directed to extrapulmonary disease manifestations mediated by viral tropism to the vascular endothelium. Here, we report a case of an adult patient with COVID-19 who presented to the emergency department with neurological signs disproportionate to pulmonary symptoms and was found to have a subacute ischemic stroke. Imaging studies suggested an active inflammatory vasculopathy. The case highlights the utility of vascular wall imaging studies when positive findings are present on emergent CT angiography. Current treatment algorithms should consider the addition of adjunct intracranial vessel wall imaging to assess for inflammatory vasculopathy when a patient with acute or recent COVID infection presents to the emergency department with stroke.

Acute coronary syndrome is a rare complication of vasculitis. We present a case of fulminant medium-vessel vasculitis, most likely PAN, complicated by STEMI and stroke, that was successfully treated with percutaneous revascularization, high-quality stroke care, and immunosuppression. This case highlights the importance of prompt diagnosis and treatment of vasculitis and the recognition of coronary and cerebral ischemia as potentially serious complications.

Introduction: The National Institutes of Health Stroke Scale (NIHSS) is widely used for rapid assessment of neurologic deficits in acute stroke. Multiple components of the scale require intact language function, which may be difficult for English-speaking providers to assess in non-English speaking patients (NESP). We sought to characterize patterns of NIHSS scoring in English-speaking patients (ESP) and NESP. Methods: This was a retrospective study of consecutive stroke alert cases who presented to the emergency department at our primarily English-speaking comprehensive stroke center. Baseline characteristics and clinical data including NIHSS components were compared between ESP and NESP. Chi-squared/Fisher’s exact statistics were used to compare frequencies and T-tests were used to compare means. Relative risks were calculated for language effects on NIHSS components, controlling for gender, age, race, and stroke diagnosis. Results: A total of 1166 patients were included, of which 87.5% were ESP and 12.5% were NESP. There were no significant differences between groups in total NIHSS scores or in frequencies of stroke diagnosis, tissue plasminogen activator treatment, or endovascular treatment. For individual NIHSS components, NESP were more likely than ESP to score for level of consciousness questions (34.9% vs 22.3%, adjusted RR 1.91, CL 1.39-2.62, p=0.0005), level of consciousness commands (21.9% vs 10.1%, adjusted RR 3.62, CL 2.42-5.43, p Conclusions: Despite similarities in total NIHSS scoring between NESP and ESP, scoring of individual components heavily dependent on language function and comprehension differed between groups. NESP were more likely to be assessed as aphasic, unable to answer questions, and unable to follow commands. Disparities in NIHSS scoring trends raise questions for further investigation into possible underlying pathophysiologic mechanisms, potential provider biases from language barriers that may influence clinical assessment, and the role of more inclusive screening tools and interventions to help mitigate these gaps.

Objective To determine the feasibility of using a machine learning algorithm to screen for large vessel occlusions (LVO) in the Emergency Department (ED). Materials and methods A retrospective cohort of consecutive ED stroke alerts at a large comprehensive stroke center was analyzed. The primary outcome was diagnosis of LVO at discharge. Components of the National Institutes of Health Stroke Scale (NIHSS) were used in various clinical methods and machine learning algorithms to predict LVO, and the results were compared with the baseline method (aggregate NIHSS score with threshold of 6). The Area-Under-Curve (AUC) was used to measure the overall performance of the models. Bootstrapping (n = 1000) was applied for the statistical analysis. Results Of 1133 total patients, 67 were diagnosed with LVO. A Gaussian Process (GP) algorithm significantly outperformed other methods including the baseline methods. AUC score for the GP algorithm was 0.874 ± 0.025, compared with the simple aggregate NIHSS score, which had an AUC score of 0.819 ± 0.024. A dual-stage GP algorithm is proposed, which offers flexible threshold settings for different patient populations, and achieved an overall sensitivity of 0.903 and specificity of 0.626, in which sensitivity of 0.99 was achieved for high-risk patients (defined as initial NIHSS score > 6). Conclusion Machine learning using a Gaussian Process algorithm outperformed a clinical cutoff using the aggregate NIHSS score for LVO diagnosis. Future studies would be beneficial in exploring prospective interventions developed using machine learning in screening for LVOs in the emergent setting.

Background Evidence is conflicting about a causal role of inflammation in psychosis and, specifically, regarding antibodies binding to neuronal membrane targets, especially N-methyl-D-aspartate receptors. NMDAR, LGI1 and GABA-A antibodies were found more prevalent in people with psychosis than in healthy controls. We aim to test whether these antibodies are pathogenic and may cause isolated psychosis. The SINAPPS2 phase IIa double-blinded randomised controlled trial will test the efficacy and safety of immunoglobulin and rituximab treatment versus placebo for patients with acute psychosis symptoms as added to psychiatric standard of care. Methods We will screen approximately 2500 adult patients with acute psychosis to identify 160 with antibody-positive psychosis without co-existing neurological disease and recruit about 80 eligible participants to the trial in the period from September 2017 to September 2021 across the UK. Eligible patients will be randomised 1:1 either to intravenous immunoglobulin (IVIG) followed by rituximab or to placebo infusions of 1% albumin followed by 0.9% sodium chloride, respectively. To detect a time-to-symptomatic-recovery hazard ratio of 0.322 with a power of 80%, 56 participants are needed to complete the trial, allowing for up to 12 participants to drop out of each group. Eligible patients will be randomised and assessed at baseline within 4 weeks of their eligibility confirmation. The treatment will start with IVIG or 1% albumin placebo infusions over 2–4 consecutive days no later than 7 days from baseline. It will continue 4–5 weeks later with a rituximab or sodium chloride placebo infusion and will end 2–3 weeks after this with another rituximab or placebo infusion. The primary outcome is the time to symptomatic recovery defined as symptomatic remission sustained for at least 6 months on the following Positive and Negative Syndrome Scale items: P1, P2, P3, N1, N4, N6, G5 and G9. Participants will be followed for 12 months from the first day of treatment or, where sustained remission begins after the first 6 months, for an additional minimum of 6 months to assess later response. Discussion The SINAPPS2 trial aims to test whether immunotherapy is efficacious and safe in psychosis associated with anti-neuronal membrane antibodies. Trial registration ISRCTN, 11177045. Registered on 2 May 2017. EudraCT, 2016-000118-31. Registered on 22 November 2016. ClinicalTrials.gov, NCT03194815. Registered on 21 June 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3336-1) contains supplementary material, which is available to authorized users.

Antibodies against N-methyl D-aspartate receptor (NMDAR) and other neuronal cell surface targets are recognised associations of immunotherapy-responsive autoimmune encephalitis. Initially, patients present with symptoms of behavioural change and psychosis, often subsequently developing seizures and cognitive impairment, rapidly progressing over a few weeks to develop a life-threatening combination of autonomic instability and loss of consciousness.1 There is in vitro and in vivo evidence that these antibodies are pathogenic and directly cause encephalitis. Although never formally demonstrated in a controlled trial, open label clinical studies show that patients receiving immunotherapy, such as intravenous immunoglobulins (IVIG) or plasma exchange (PLEX) with or without corticosteroids, have better recovery and reduced relapse rates. Therefore, clinical consensus guidelines recommend that immunotherapy should be given as soon as possible after diagnosis.2 Several studies have assessed the prevalence of these antibodies in purely psychiatric presentations. NMDAR antibodies are the most commonly identified; in some studies, these are twice as prevalent in patients with early psychosis than in healthy controls, being seen at rates of between 4% and 12% of cases (OR 2.70, 95% CI 1.11 to 6.56).3 We have seen a number of such cases which respond to immunotherapy in an uncontrolled study.4 We have therefore proposed a randomised, placebo-controlled trial of immunotherapy in psychosis associated with antineuronal antibodies, to inform clinical practice and to advance understanding of the …

Background: With newly-extended treatment windows for endovascular therapy in emergent large vessel occlusions, it is increasingly important to identify thrombectomy-eligible patients without overwhelming resources dedicated to acute stroke care. We devised a simple paradigm to classify patient's presenting neurologic symptoms to screen for large vessel occlusions. Methods: We reviewed the presenting symptoms, imaging findings, and final diagnoses of consecutive emergency department stroke alert cases. Patients were classified based on their neurologic exams as focal objective, focal subjective, or nonfocal. Outcomes of final diagnoses of acute ischemic stroke and large vessel occlusions were compared across groups. Comparisons were made to other large vessel occlusion prediction scales. Results: Of 521 patients, 342 (65.6%) were categorized as focal objective, 142 (27.2%) as focal subjective, and 37 (7.1%) as nonfocal. Ischemic stroke and large vessel occlusions were diagnosed in 114 (21.9%) and 27 (5.2%) of patients, respectively. Classification as focal objective significantly predicted stroke (odds ratio 3.77; 95% confidence interval 2.17-6.55) and captured all large vessel occlusions (P = .0001). The focal objective categorization was the only tool which achieved 100% sensitivity for large vessel occlusions (with a specificity of 36%) compared to other large vessel occlusion prediction tools. Conclusions: Patients who presented as stroke alerts without focal neurologic symptoms were unlikely to have large vessel occlusions. With high sensitivity, classifying patients' neurologic exams into focal objective versus subjective or nonfocal categories may serve as a useful tool to screen for large vessel occlusions and prevent unnecessary emergent workup in patients unlikely to be endovascular candidates.