We describe a man with an intracranial dural arteriovenous fistula that presented as a subacute longitudinally extensive cervical myelopathy. The uncommon location of the fistula and the absence of specific radiological signs resulted in initial misdiagnosis as longitudinally extensive transverse myelitis. Neurologists should have a high index of suspicion for dural arteriovenous fistula in older men, especially those with subacute or chronic symptoms, acellular cerebrospinal fluid and, particularly, if there is neurological deterioration soon after corticosteroid treatment. Patients need early angiography to identify this treatable cause of myelopathy.

Background: Depression has been identified as a risk factor for acute cerebrovascular events. Due to limited data focused on young females, we studied the burden and impact of comorbid depression on outcomes of acute ischemic stroke (AIS)-related admissions in young women of the reproductive age group. Methods: We used the National Inpatient Sample (2018) to identify admissions of young females (age 18-44 years) with AIS; and further classified it into two demographically (age, race, payer status, income) matched (1:1) groups based on the presence of comorbid depression. Comorbidities and outcomes were compared using relevant ICD-10 codes. Multivariable regression was used to analyze the association of comorbid depression with in-hospital mortality. Results: In 15850 young females admitted with AIS in 2018, 2465 (15.6%) had comorbid depression. Post-matching, the study cohort consisted of 4610 women admitted with AIS (Median age: 37, 66.2% whites) and 2305 women in each cohort, with and without depression. The matched AIS-depression arm often had younger women (median 37 vs 39 years), patients from the lower-income quartile (47.3% vs. 34.5%), and higher rates of obesity, peripheral vascular disease, and prior history of stroke but a lower prevalence of CVD risk factors [Table 1]. The depression arm had a non-significant odd of all-cause mortality (OR 1.32, 95%CI:0.64-2.74) when adjusted for sociodemographic confounders and comorbid risk factors (p=0.452). The LOS was shorter (median 4 vs 5 days) with comparable hospital charges in the depression arm vs. no depression arm (p<0.001). Conclusion: This study revealed a nearly 15% burden of depression in young females admitted for AIS without significant impact on all-cause mortality when controlled for confounders. The impact of depression on long-term AIS outcomes needs further evaluation.

Background: Mechanical thrombectomy (MT) has been proven to be a successful treatment option for patients with acute ischemic stroke (AIS) in numerous randomized controlled trials. The majority of trials underrepresent patients aged 70 and above, and there is little contemporary data on regional trends and variation in mortality. Methods: This retrospective study using the National Inpatient Sample (2016-2019) seeks to identify any regional relationships between geriatric patients' in-hospital mortality after MT for AIS at urban facilities and trends in inpatient mortality. Regional Inpatient mortality based on sex and race and trends between 2016 and 2019 were assessed. Results: Our study group consisted of 52455 AIS-MT admissions (median 78 yrs, 57.1% male, 77.2% white, 89.6% Medicare enrollees) with a 14.1% inpatient mortality rate. Despite having a lower comparative burden of traditional CVD risk factors, the hospitals from the Northeast had a higher inpatient mortality rate (17.2%, n=1650) and risk (adjusted OR:1.25, 95% CI:1.03-1.51) than the other regions. Similar trends were observed in male (18.1%), females (16.6%), white (17.3%) and black (13.8%) participants (P<0.001) undergoing AIS-MT. Highest inpatient mortality among Hispanics was linked to Midwest-based participants (16.2%) without regional variation in rates for Asians. There were declining trends in mortality between 2016 to 2019 in West region without any change in other regions (from 14.0% to 11.5%, ptrend=0.002) (Fig. 1) . Conclusion: Among demographically comparable geriatric patients with AIS undergoing MT in the US, the Northeast region admissions showed the highest inpatient mortality even after controlling for confounding factors with a relatively lower burden of CVD risk factors. This disparity warrants further research to validate these findings.

Background: Despite previous studies exploring female reproductive factors, early menarche and its impact on stroke risk remains under-reported. This systematic review seeks to further explore this correlation. Methods: PubMed, SCOPUS and EMBASE databases were systematically reviewed for studies reporting long-term incidence and odds of stroke in patients who had menarche at an early age vs. menarche at a normal age. Random effects models were used for the meta-analysis and subgroup analysis. I2 statistics were used to identify substantial (>75%) heterogeneity. A sensitivity analysis was performed using the leave-one-out method. Results: Ten prospective studies with a total of 1,971,454 patients were included and the odds of stroke were evaluated for patients with early menarche vs controls. Overall unadjusted odds for stroke with early menarche was 1.14 (95%CI 1.08 -1.20, p<0.01, I2=0%). (Fig.1b) Adjusted odds ratio; [aOR 1.22 (95% CI 1.08 - 1.39), I2=86.85%, p<0.01]. (Fig. 1a) Leave-one-out sensitivity analysis confirmed equivalent results. (Fig.1c) On subgroup analysis, studies from the USA with early menarche had the highest stroke risk of countries reported (1.48, 95%CI 1.04-2.09) followed by China (1.26, 95% CI 1.09-1.45) and the UK (1.08, 95%CI 0.96-1.21). There was stronger stroke association with mean/median age cohort ≥ 60 yrs (1.43, 95% CI 1.08 - 1.89) vs <60 yrs (1.18, 95% CI 1.03 - 1.36). Conclusions: This meta-analysis revealed that early menarche is associated with a higher risk of stroke with the strongest association in women from the USA.

Background: Cervical spondylosis is a chronic degenerative lesion of the cervical intervertebral discs causing axial neck pain, cervical radiculopathy and myelopathy. This study was undertaken to study the clinical and radiological correlation in cervical spondylosis with respect to clinical and radiological findings.Methods: A prospective observational study was done on 100 patients with cervical spondylosis treated in a tertiary care centre of South Kerala. The sociodemographic details, clinical and radiological findings were recorded. Nurick’s grading and Modified Japanese orthopaedic association cervical spine myelopathy scoring was done. Data collected was analyzed using Microsoft Excel 2010 and results expressed in proportions.Results: Maximum prevalence was seen in 40-49 years group with male predominance. Majority of the patients had neck pain, sensory numbness and motor weakness. Spurling’s sign and Lhermitt’s sign was positive in 60% and 47% patients respectively. Complete paralysis was seen on both sides in 12% patients at wrist joint and 9% each in elbow and knee joints. Grade II cervical spondylosis was seen in 43%. Modified Japanese orthopaedic association score was less than 18 in all patients. Canal size was reduced in many. The clinical and radiological findings were consistent.Conclusions: Cervical spondylosis is seen in those above 30 years of age with male predominance. Clinical and radiological findings are consistent with each other. Further studies are advised for better correlation.