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Introduction/Aims: Females with generalized myasthenia gravis (gMG) report lower quality of life (QoL) and have more severe disease than males. Sex differences in disease characteristics exist, however whether there are sex differences in the treatment of gMG that may contribute to QoL disparities is unknown. Our objective is to determine whether there are sex differences in the treatment of gMG. Methods: We performed a single‐center retrospective study of people diagnosed with gMG at the University of Calgary between 1997 and 2021. Primary outcome was proportion starting treatment and secondary outcome was time from diagnosis to treatment initiation. Treatments included pyridostigmine, prednisone, steroid sparing therapies (azathioprine, mycophenolate mofetil [MMF], methotrexate [MTX], or tacrolimus), intravenous immunoglobulin (IVIg), plasmapheresis, rituximab, eculizumab, cyclosporine, stem cell transplantation, and thymectomy. Multivariable logistic and Cox proportional hazards regression models were used to examine treatment associations with sex, adjusted for time from onset to diagnosis, age at diagnosis, presence of thymoma, and antibody status. Results: A total of 179 people with gMG were included (41.9% female). Odds of starting treatment were not statistically associated with sex after adjustment for confounders and correction for multiple testing. Results of the secondary analysis using time to treatment initiation as the outcome were similar. Discussion: We found no sex differences in odds of starting treatment or time to treatment initiation that might explain previously observed sex‐based differences in QoL. Future work should capture physician and patient treatment preferences that may influence disease management. [ABSTRACT FROM AUTHOR]

Background: Endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) have an unclear benefit in those with pre-stroke dementia or cognitive impairment, as these patients were often excluded from landmark stroke trials. We performed a systematic review and meta-analysis to assess the outcomes of IVT and EVT in these populations. Aims: Our systematic review, conforming to the Meta-Analysis of Observational Studies in Epidemiology guidelines, investigated studies on acute ischemic stroke patients with pre-stroke dementia or cognitive impairment treated with IVT or EVT. Primary outcome was favorable 90-day outcome (mRS 0–2). Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (SICH), and radiographic intracranial hemorrhage (ICH). Summary of review: Nine articles were identified, with five observational studies of IVT use in patients with (n = 1078) and without dementia (n = 2805) being selected for the meta-analysis. There were no significant differences in favorable outcome (adjusted OR: 0.61, 95% CI 0.24–1.59), mortality (unadjusted OR: 1.19, 95% CI 0.86–1.64), ICH (unadjusted OR: 1.32, 95% CI 0.79–2.19), and symptomatic ICH (unadjusted OR: 0.94, 95% CI 0.70–1.25) for patients undergoing IVT with pre-stroke dementia versus those without. One EVT study (n = 615 with dementia vs n = 9600 without) found no significant differences in outcomes apart from an increased odds of ICH for those with pre-existing dementia (adjusted OR: 1.57, 95% CI 1.03–2.40). A pooled analysis of three IVT studies showed no significant association of cognitive impairment (n = 93 vs n = 211 without) with all assessed outcomes, whereas a study of EVT found that pre-stroke cognitive impairment was associated with poor 90-day outcomes (mRS 3–6). Conclusion: These results suggest no substantial safety issues in the use of IVT or EVT for patients with pre-existing dementia or cognitive impairment compared to those without. However, the efficacy of these therapies in this demographic remains uncertain. Further rigorous studies that include a more nuanced outcome measurement approach are warranted. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499. [ABSTRACT FROM AUTHOR]

A 70-year-old woman developed chronic ataxic neuropathy, ophthalmoplegia, immunoglobulin M paraprotein, cold agglutinins, and disialosyl antibodies after receiving the mRNA COVID-19 vaccine. Her symptoms included sensory issues, weakness, incoordination, and diplopia, progressing over 12 months. Treatment with intravenous immunoglobulin (IVIg) showed improvement, but symptoms recurred, requiring repeat IVIg. CANOMAD, a rare acquired neuropathy, may be triggered by immunological factors, with vaccination possibly playing a role, although more research is needed to establish causation. [Extracted from the article]

Background Trials of endovascular thrombectomy (EVT) for acute stroke have excluded patients with premorbid disability. Observational studies may help inform consideration of EVT in this population. We aimed to assess the effectiveness and safety of EVT in patients with pre-morbid disability. Methods According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE and Embase for studies describing outcomes in patients with pre-morbid disability (modified Rankin Scale (mRS) 2--5), treated with EVT or medical management (MM). Random-effects meta-analysis was used to pool outcomes including 90-day return to baseline mRS, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Results We analyzed 14 studies of patients with premorbid disability (mRS 2--5, 1373 EVT and 253 MM). The rate of return to baseline mRS was 30.0% (95% CI 25.3% to 34.7%) in patients treated with EVT. Compared with medical therapy, EVT was associated with a higher likelihood of return to baseline mRS (OR 2.37, 95% CI 1.39 to 4.04) and a trend towards lower mortality (OR 0.68, 95% CI 0.46 to 1.02), with similar odds of sICH (OR 1.01, 95% CI 0.49 to 2.08). In studies comparing patients with versus without pre-morbid disability treated with EVT, similar results were found except that pre-morbid disability, when defined more strictly as mRS 3--5, was associated with mortality (OR 3.49, p<0.001). Conclusion In eligible patients with pre-morbid disability, observational studies suggest that EVT carries a higher chance of return to baseline mRS compared with patients treated with MM or without pre-morbid disability, although with higher mortality than patients without pre-morbid disability. These findings argue against the routine exclusion of such patients from EVT and merit validation with randomized trials. [ABSTRACT FROM AUTHOR]

Introduction/Aims: Up to 25% of patients with myasthenia gravis (MG) have refractory disease despite trials of multiple immunosuppressants. Several case series describe acetylcholine receptor antibody‐positive (AChR) MG patients treated with autologous hematopoietic stem cell transplant (HSCT). In this report, we describe three patients with anti‐muscle‐specific kinase (MuSK) MG treated with HSCT. Methods: We included all patients who had undergone HSCT with anti‐MuSK myasthenia gravis identified through the records of the Alberta Blood and Marrow Transplant Program. We collected demographic and clinical data including validated MG scales as well as questionnaire data. Results: All 3 patients had severe disease (Myasthenia Gravis Foundation of America score IVb‐V) and were refractory to multiple treatments, including rituximab. All patients improved with no clinical manifestations or mild symptoms and remained as such for 2, 3.5, and 5.5 y. Adverse events ranged from treatable infections and transient dyspnea to persistent fatigue and premature menopause. The average worst Myasthenia Gravis Activities of Daily Living (MG‐ADL) scores improved from 14.7 before to 0.3 after HSCT. The mean worst Myasthenia Gravis Quality of Life Questionnaire (MG‐QoL15) scores improved from 26.7 to 0. All patients reported they would undergo transplant again for their MG. Discussion: We describe three patients with anti‐MuSK MG treated with HSCT, all of whom became symptom free from MG with a tolerable side effect profile. In patients with severe refractory anti‐MuSK MG, it may be reasonable to consider HSCT. [ABSTRACT FROM AUTHOR]

Background: There are variations in computed tomography (CT) protocols used for evaluating sialolithiasis, with some protocols including acquisitions before and after IV contrast administration. Dual-energy CT (DECT) can be used to generate virtual unenhanced (VUE) images, potentially precluding the need for an uninfused scan. Purpose: In this study, we performed a survey in order to assess variations in the imaging approach for sialolithiasis and evaluated the accuracy of DECT VUE images for the detection of salivary stones. Material and Methods: Practice variations were evaluated by an online survey of the membership of the American Society of Neuroradiology. We then identified 28 patients with salivary gland calcifications matched with 28 negative controls that had both an unenhanced and a contrast-enhanced acquisition performed as DECT. A total of 123 major salivary gland calcifications and 85 tonsilloliths were evaluated and the true unenhanced series was used as gold standard. Results: The survey revealed substantial variations in CT protocols used for sialolithiasis. On a per-patient basis, DECT VUE had 96.4% sensitivity and 100% specificity. On a per-calcification basis, sensitivity and specificity was 100% for stones > 2 mm but dropped for smaller calcifications. The false-negative cases corresponded to clinically insignificant, intra-glandular parotid calcifications. Inter-reader agreement was excellent (0.9256). Conclusion: This study confirms that there are significant variations in CT protocols used for evaluation of sialolithiasis. A single contrast-enhanced DECT acquisition with reconstruction of VUE may represent an attractive, streamlined alternative and enable the elimination of the true unenhanced phase and associated radiation exposure. [ABSTRACT FROM AUTHOR]