Objective(s):To systematically review literature on brief screening tools used to detect and differentiate between normal cognition and neurocognitive impairment and HIV-associated neurocognitive disorders (HANDs) in adult populations of persons with HIV.Design:A formal systematic review.Methods:We searched six electronic databases in 2011 and contacted experts to identify relevant studies published through May 2012. We selected empirical studies that focused on evaluating brief screening tools (<20 min) for neurocognitive impairment in persons with HIV. Two reviewers independently reviewed retrieved literature for potential relevance and methodological quality. Meta-analyses were completed on screening tools that had sufficient data.Results:Fifty-one studies met inclusion criteria; we focused on 31 studies that compared brief screening tools with reference tests. Within these 31 studies, 39 tools were evaluated and 67% used a comprehensive neuropsychological battery as a reference. The majority of these studies evaluated HIV-associated dementia (HAD). Meta-analyses demonstrated that the HIV Dementia Scale (HDS) has poor pooled sensitivity (0.48) and the International HIV Dementia Scale (IHDS) has moderate pooled sensitivity (0.62) in detecting a range of cognitive impairment. Five newer screening tools had relatively good sensitivities (>0.70); however, none of the tools differentiated HAND conditions well enough to suggest broader use. There were significant methodological shortcomings noted in most studies.Conclusion:HDS and IHDS perform well to screen for HAD but poorly for milder HAND conditions. Further investigation, with improved methodology, is required to understand the utility of newer screening tools for HAND; further tools may need to be developed for milder HAND conditions.

Objective: To study the short and long term differences in outcome between patients >80 years of age and those (79 years of age who received intravenous recombinant tissue plasminogen activator (iv rt-PA) for acute stroke within the first 3 hours of symptom onset. Methods: We studied consecutive patients treated with iv rt-PA for acute stroke, with prospective follow up of up to 3 years. Outcome measures included National Institutes of Health Stroke Scale (NIHSS) score, Barthel Index (BI), modified Rankin score (MRS), and stroke mortality. Patients were split into two groups: younger ( (79 years) and older (>80 years). Results: There were 65 patients in the younger cohort and 31 patients in the older. Older patients were more likely to present with more severe baseline stroke (p = 0.04; odds ratio (OR) 3.04; 95% confidence interval (CI) 1.03 to 8.98). Stroke mortality at 90 days was 10.8% in the younger and 32.3% in the older cohort (p = 0.01). At 90 days' follow up, patients in the older cohort with more severe stroke (NIHSS score >11) were nearly 10 times more likely to have poor outcome compared with their younger counterparts presenting with severe stroke (p = 0.001; OR = 10.36; 95% CI 2.16 to 49.20). Baseline stroke severity and age were the only independent and equal predictors for stroke outcome. No threshold was found for age or baseline stroke severity predicting outcome. Conclusion: Older patients presenting with more severe baseline stroke are much less likely to benefit from iv rt-PA as compared with their younger counterparts.

Background and Purpose-The Oxfordshire Community Stroke Project (OCSP) is a common clinical stroke classification tool. We evaluated the accuracy of OCSP classification with a prospective magnetic resonance imaging (MRI) study. Methods-Stroke/transient ischemic attack patients presenting within 48 hours of onset were included in the study (nϭ130). Following computed tomography scan, OCSP classification, total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), lacunar circulation infarcts (LACI), and posterior circulation infarcts (POCI) were performed by 3 independent examiners. All patients underwent diffusion-weighted MRI with planimetric volume measurement and classification into OCSP categories, organized by lesion location. Results-Patients were clinically classified as TACI (12 patients

Immune reconstitution inflammatory syndrome in the nervous system (NeuroIRIS) remains an uncommon complication of combination antiretroviral therapy (cART) but with a potentially poor outcome. Initiation of cART in very immunosuppressed patients requires close monitoring to manage NeuroIRIS in an expedient manner.

ObjectivesThe aim of the study was to determine the risk factors predictive of symptomatic HIV-associated neurocognitive disorders (sHAND) among HIV-infected patients receiving active medical care. MethodsBaseline demographic and clinical characteristics were analysed in patients with sHAND (HIV-associated dementia and minor neurocognitive disorder) in a population-based longitudinal cohort of HIV-infected patients with access to universal health care, including combination antiretroviral therapy (cART) from 1999 to 2008. Variables evaluated for their association with sHAND included age and ethnicity, survival duration with HIV-1 infection, vascular disease risk factors, and laboratory indices such as blood CD4 T-cell count at its nadir and at cART initiation, using both univariable and multivariable logistic regression models. ResultsA total of 1320 patients were investigated, including the patients diagnosed with sHAND (n = 90) during the study period. In univariable analyses, increased age, increased length of survival with HIV, low nadir CD4 and CD8 T-cell counts, high baseline viral load (> 1 000 000 HIV-1 RNA copies/mL), and African origin were predictive of a diagnosis of sHAND (P < 0.05). In multivariable analysis, increased age, increased length of survival, low nadir CD4 T-cell counts, and high baseline viral load remained predictive of sHAND (P < 0.05). Remarkably, CD4 T-cell counts at cART initiation, hepatitis C virus coinfection, and vascular disease risk factors failed to predict sHAND in both analyses. ConclusionsIncreased age and survival duration, lower nadir CD4 T-cell counts, and higher baseline viral load were consistent predictors of the development of sHAND among persons with HIV/AIDS in universal health care, underscoring the importance of attention to these variables in clinical care. Keywords: HIV, HIV-associated dementia, HIV-associated neurocognitive disorder Accepted 26 July 2012 IntroductionWith the availability of combination antiretroviral therapy (cART), there has been a decline in the incidence and severity of HIV-associated dementia (HAD). However, HIVassociated neurocognitive disorders (HAND), which are comprised of HAD, minor neurocognitive disorder (MND) and asymptomatic neurocognitive impairment, are increasingly reported in the context of improved survival among treated HIV-1-seropositive individuals [1,2], often before the diagnosis of AIDS. A recent study performed in Switzerland reported a prevalence of HAND ranging between 64 and 84% depending on whether the subject was symptomatic for neurocognitive impairment; among those patients without symptoms, the majority of subjects were Thus, HAND remains a common and disabling problem with personal, clinical, social and economic implications despite advances in the treatment of HIV/AIDS [6]. The presence of HAND in HIV-infected patients has also been shown to be associated with increased mortality [7]. Recognized predictive or associated risk factors for the development of HAND, particularly HAD, include lower baseline CD4 T...

Mobile Stroke Unit (MSU) expedites the delivery of intravenous thrombolysis in acute stroke patients. We further evaluated the functional outcome of patients shipped to a tertiary care centre or repatriated to local hospitals after triage by MSU in acute stroke syndrome in rural northern Alberta. Consecutive patients with suspected acute stroke syndrome were included. On the basis of neurology consultation and, Computed Tomography findings, patients, who were thrombolysed or needed advanced care were transported to the Comprehensive stroke center (CSC) (Triage to CSC group). Other patients were repatriated to local hospital care (Triage to LHC group). A total of 156 patients were assessed in MSU, 73 (46.8%) were female and the mean age was 66.6 ± 15 years. One hundred and eight (69.2%) patients, including 41 (26.3%) treated with thrombolysis were transported to the CSC (Triage to CSC group) and 48 (30.8%) were repatriated to local hospital care. The diagnosis made in MSU and final diagnosis were matching in 88% (95) and 91.7% (44, p = 0.39) in Triage to CSC and Triage to LHC groups respectively. Prehospital triage by MSU of acute stroke syndrome can reliably repatriate patients to the home hospital. The proposed model has the potential to triage patients according to their medical needs by enabling treatment in home hospitals whenever reasonable.

Immune checkpoint inhibitors such as antibodies to cytotoxic lymphocyte-associated protein 4 (ipilimumab) and programmed cell-death 1 (pembrolizumab, nivolumab) molecules have been used in non-small cell lung cancer, metastatic melanoma, and renal-cell carcinoma, among others. With these agents, immune-related adverse events (irAEs) can occur, including those affecting the neurological axis. In this review, high-grade neurological irAEs associated with immune checkpoint inhibitors including cases of Guillain-Barré syndrome (GBS) and myasthenia gravis (MG) are analyzed. Based on current literature and experience at our institution with 4 cases of high-grade neurological irAEs associated with immune checkpoint inhibitors (2 cases of GBS, 1 case of meningo-radiculitis, and 1 case of myelitis), we propose an algorithm for the investigation and treatment of high-grade neurological irAEs. Our algorithm incorporates both peripheral nervous system (meningo-radiculitis, GBS, MG) and central nervous system presentations (myelitis, encephalopathy). It is anticipated that our algorithm will be useful both to oncologists and neurologists who are likely to encounter neurological irAEs more frequently in the future as immune checkpoint inhibitors become more widely used.

We report the cases of 3 patients with fatal, disseminated Mycobacterium chimaera infections following cardiac surgeries. Progressive neurocognitive decline and death were explained by active granulomatous encephalitis, with widespread involvement of other organs. This syndrome is clinically elusive and, thus, may have caused deaths in prior reported series.