The Neurohospitalist

The utilization and outcomes of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) in the presence of brain tumors has not been studied. Using the National Inpatient Sample (NIS), we performed a retrospective analysis of the rate of utilization of EVT in patients with AIS and brain tumors and their odds of in-hospital mortality and home discharge.

All adult (≥18 years) AIS patients with brain tumors of malignant, benign, or undetermined subtypes, and EVT use were identified in the NIS (2016-2019). Outcomes were odds of home discharge and in-hospital mortality, adjusted for age, sex, race, income, insurance, hospital size, intravenous tissue plasminogen activator (IV-tPA) use, and clinical severity of hospital admission.

Of 533,351 AIS patients, 7070 (1.3%) had brain tumors. Sixty-two percent were malignant, 33% benign, and 5.2% undetermined. Patients with brain tumors less frequently received IV-tPA (3.4% vs 10.3%) and EVT (1.9% vs 3.6%) (P < 0.001). Home discharge after EVT was similar in patients with vs without brain tumors, for all tumor subtypes (28.0% vs 28.4%, P = 0.933). In-hospital mortality was higher with brain tumors (22.6% vs 13.0%, P < 0.001), but largely driven by malignant subtype. In adjusted analysis, only patients with malignant tumors experienced greater in-hospital death after EVT (aOR: 2.78, 95% CI: 1.61-4.80).

Patients with malignant brain tumors may have higher in-hospital mortality after EVT but similar rate of home discharge. These results are limited by lack of information on confounders such as brain tumor characteristics and causes of mortality in the NIS.

Insulin Resistance (IR) impact on Acute Ischemic Stroke (AIS) outcomes has been challenging to assess due to the lack of a readily available IR biomarker in acute settings. The Triglyceride-Glucose (TyG) index is a novel surrogate marker for IR that may help bridge this gap. We aimed to evaluate the relationship between IR and clinical outcomes after AIS in patients with large vessel occlusion (LVO).

This single-center retrospective cohort study included patients presenting between 2010 and 2022 with internal carotid artery (ICA) or middle cerebral artery (M1) occlusion who underwent endovascular treatment (EVT). Eligibility criteria were: pre-stroke modified Rankin Scale (mRS) score ≤2 and available fasting triglyceride and glucose levels. The TyG index was calculated as Ln [triglyceride (mg/dL) × glucose (mg/dL)]/2. Multivariable ordinal logistic regression was performed to assess the association between the TyG index and other demographic variables on 90-day mRS.

Among 155 patients, 53% were males, and 47% were females. TyG index was significantly associated association with 90-day mRS (OR = 2.04, P < 0.01). Other associated variables included age (OR = 1.05, P < 0.01) and smoking status, with former smokers having lower odds of worse outcomes (OR = 0.44, P = 0.03).

Lower TyG index values, indicative of reduced IR, were associated with better functional outcomes following EVT in AIS patients with LVO. Future studies should establish optimal TyG index cut-off values to refine vascular risk management and improve stroke outcomes.

Spontaneous intracranial hypotension (SIH) results from cerebrospinal fluid (CSF) leakage due to spinal dural tears or CSF–venous fistulas. Orthostatic headache is the hallmark presentation, though severe downward displacement of the brainstem may lead to altered consciousness or coma. Definitive treatments include targeted epidural blood patches, venous embolization, or surgical repair.

This article reviews the role of the Trendelenburg position as a temporizing measure in the acute management of SIH. We describe the correct technique, physiologic rationale, and practical considerations for its application, with attention to both therapeutic and diagnostic utility.

Positioning the patient with the feet elevated above the head can reduce brain sag and provide short-term symptomatic relief while awaiting definitive treatment. Although the Trendelenburg position is widely used in practice, supporting evidence remains limited, and clinicians must be aware of its benefits, indications, and inherent limitations. Its appropriate application may assist in stabilizing patients with acute or severe SIH, particularly those with impaired consciousness, until more definitive interventions are pursued.

Idiopathic intracranial hypertension (IIH) typically presents with chronic headache, pulsatile tinnitus, transient visual obscurations, and papilledema. The fulminant form, representing 2–3% of cases, is characterized by rapid visual decline within four weeks of symptom onset. Sixth cranial nerve palsy is the most frequently reported cranial neuropathy in IIH, whereas involvement of other cranial nerves is exceedingly rare.

We describe a 16-year-old girl with fulminant IIH and oculomotor nerve palsy associated with risperidone-induced weight gain. She presented with one week of nausea, vomiting, and occipital headache, followed by blurry vision and right ptosis. Examination revealed partial right oculomotor palsy with ptosis, a dilated pupil without a relative afferent pupillary defect, and severe bilateral papilledema. Neuroimaging excluded mass lesion, aneurysm, and inflammation, but showed findings consistent with IIH. Lumbar puncture revealed an opening pressure of 86 cm H₂O with normal CSF composition. Due to progressive symptoms, she underwent ventriculoperitoneal shunting, with near-complete resolution of oculomotor palsy and mild residual ptosis at two-week follow-up.

Oculomotor nerve palsy is a rare manifestation of IIH; including our case, we identified eight patients (seven female) presenting in the setting of IIH. All presented with new-onset IIH, and three were fulminant cases with markedly elevated CSF pressures (>50 cm H2O) and ultimately received shunting. Fulminant IIH should be considered in the differential diagnosis of acute oculomotor palsy, particularly when risk factors such as recent weight gain or medication use are present, as early recognition and CSF diversion are important to prevent irreversible vision or cranial nerve deficits.

Neurenteric cysts are rare congenital lesions of endodermal origin that typically present with slowly progressive myelopathy. Accounting for less than 2% of all spinal tumors, they most often occur in the cervical and upper thoracic spine. Acute neurological deterioration due to a neurenteric cyst is uncommon and represents a clinical emergency.

We describe an 18-year-old woman with no prior medical history who developed sudden-onset neck pain, rapidly progressive quadriparesis, and respiratory compromise. Neurological examination revealed upper motor neuron signs with a C4 sensory level. Cervical magnetic resonance imaging showed a ventral intradural extramedullary cystic lesion at the C2–C3 level, compressing the spinal cord and producing cord edema. Emergent posterior C2–C3 laminectomy was performed, and a tense mucin-filled cyst was completely excised. Histopathology demonstrated a columnar mucinous epithelium with goblet cells, confirming the diagnosis of a neurenteric cyst. Postoperatively, the patient exhibited substantial neurological recovery, regaining independent ambulation within three months. Follow-up imaging at six months showed no recurrence.

This case underscores two important lessons. First, although neurenteric cysts are classically indolent, they may present with abrupt, life-threatening neurological decline, even in the absence of associated congenital vertebral anomalies. Second, prompt surgical decompression with gross total resection remains the cornerstone of management, offering excellent potential for recovery. Given the risk of recurrence, radiological surveillance is warranted. This report adds to the limited literature on cervical neurenteric cysts with hyperacute presentations and emphasizes the need for early recognition and timely intervention to optimize outcomes.