Background and Purpose: Medical-legal claims for malpractice relating to the use of alteplase for acute ischemic stroke (AIS) are usually for failure to treat rather than for complications. The advent of mechanical thrombectomy (MT) as a standard of AIS treatment has added a new dimension to the medical-legal landscape as there is a need for the delivery of a higher level of care creating the potential for delays and errors associated with such treatment. Information on causes of malpractice related to mechanical thrombectomy (MT) is currently lacking. Methods: We conducted a systematic review of legal databases (Westlaw, LexisNexis, Google Scholar Case Law, and VerdictSearch) to identify medical malpractice cases with and without verdicts filed in the United States up to March 31, 2021 which pertained to performance or non-performance of MT for AIS. We collected various case characteristics, case outcomes, and root causes for malpractice claims. Results: We found 25 cases, 16 of which alleged failure to treat with MT, 8 for harm due to delay in treatment and 1 case that alleged complications. Root causes included delay in vascular imaging, communication breakdowns, and transportation delays. Eight cases had an outcome in favor of the defendant, 9 in favor of the plaintiff, and 8 remained to be determined. Conclusions: As with alteplase, malpractice allegations regarding MT for AIS are largely for failure to treat or delay in treatment as opposed to complications. Addressing root causes of diagnostic delay, communication breakdowns, and transportation delays may reduce subsequent malpractice risk.

Stroke is a significant public health challenge as it is the second most common cause of death and the third leading cause of disability globally. Additionally, stroke incidence and the number of stroke deaths have been rising. Efforts to prevent stroke have been made, including high-risk approaches where patients are screened for cardiovascular risk factors, and population-based approaches which attempt to reduce stroke rates by improving overall population health. We summarize studies of population-based approaches to stroke prevention involving greater than 1,000 participants identified on a PubMed database search. Based on these programs, challenges of population-based stroke prevention programs are discussed and potential keys to success are highlighted. Population-based stroke prevention programs face challenges including cost and interest of the public and certain stakeholders. Additionally, secular trends for improvement in risk factors and catastrophic adverse environmental circumstances add to the complexity of analyzing program success. Factors leading to successful programs include validated digital solutions for self-monitoring of risks, backing by global policy and legislation, flexibility to the needs of the population, intersectoral programs, community engagement, information dissemination back to the populations, and high-risk screening to develop a complementary combination approach to stroke prevention.

Non-arteritic anterior ischaemic optic neuropathy (NAION) is a common cause of vision loss in adults and is thought to be due to compromised perfusion to the optic nerve head. Patients with NAION in one eye are at risk of recurrence in the fellow eye. We report a case of sequential, bilateral NAION in a patient who was found to have a COL4A2 mutation. COL4A2 encodes a subunit of the collagen 4 protein, the major component of the human basement membranes, and has several known cerebrovascular and ocular associations.

The growth of brain health initiatives in the United States and worldwide has led to a movement to protect the brain from avoidable injury across the lifespan. With the advancement of our armamentarium of neurologic treatments and preventives during the past several decades, the field of preventive neurology has spawned. Under the umbrella of preventive neurology is perioperative brain health, an under-addressed but important topic in the field of neurology. Perioperative brain health is important because perioperative mortality may be relatively high, and morbidity as quantified by brain injury biomarkers (e.g., MRI brain) and clinical phenotypic manifestations related to stroke can be common. In this perspective, in relation to periprocedural stroke, we review the stroke mechanisms, epidemiology and risk factors, risk stratification measures and long-term outcomes, and potential mitigation and treatment opportunities. As perioperative brain health crosses many medical disciplines, multidisciplinary action is needed to bridge the knowledge gaps and reduce brain injury and attendant neurologic complications. Anesthesiologists and other healthcare professionals working in the surgical and procedural field are well-positioned to make important contributions to this growing discipline of the prevention of brain injury in the perioperative period.

Small cell carcinoma (SCC) is a neuroendocrine tumor (NET) commonly found in the lung, known for rapid proliferation and early metastasis. Extrapulmonary small cell carcinomas (ESCC) are rare, with GI tract carcinomas exceedingly so. Due to the lack of clinical data on the treatment of ESCC, the standard regimen is the same as the SCC of the lung. Documented accounts of paraneoplastic encephalomyelitis associated with NETs are also uncommon. We present a patient who suffered from neurologic deficits before being diagnosed with paraneoplastic encephalomyelitis from a duodenal ESCC. The patient presented with ear pain and hematemesis. New symptoms arose after the resolution of initial symptoms, including shortness of breath and numbness. Autoimmune workup was positive for anti-Hu antibodies. A position emission tomography (PET) scan showed increased uptake in the duodenal region. Biopsy results from a duodenal ulcer revealed poorly differentiated neuroendocrine carcinoma with positive synaptophysin and strong positivity of Ki-67, consistent with ESCC. Numerous treatments, including platinum-based chemotherapy, yielded no neurologic improvement for the patient. This case details an atypical presentation of ESCC, which should be considered in patients suspected of paraneoplastic encephalomyelitis.