Adnan I. Qureshi

Factors and outcomes associated with early and delayed aneurysm treatment in subarachnoid hemorrhage patients in the United States.

BACKGROUNDnRecent studies from selected centers have shown that early surgical treatment of aneurysms in subarachnoid hemorrhage (SAH) patients can improve outcomes. These results have not been validated in clinical practice at large.nnnOBJECTIVEnTo identify factors and outcomes associated with timing of ruptured intracranial aneurysm obliteration treatment in patients with SAH after hospitalization in the United States.nnnMETHODSnWe analyzed the data from the Nationwide Inpatient Sample (2005-2008) for all patients presenting with primary diagnosis of SAH, receiving aneurysm treatment (endovascular coil embolization or surgical clip placement). Early treatment was defined as aneurysm treatment performed within 48 hours and delayed treatment if treatment was performed after 48 hours of admission.nnnRESULTSnOf 32u2009048 patients with SAH who underwent aneurysm treatment, 24u2009085 (75.2%) underwent early treatment and 7963 (24.8%) underwent delayed treatment. Female sex (P = .002), endovascular embolization (P < .001), and weekday admission (P < .001) were independent predictors of early treatment. In the early treatment group, patients were more likely discharged with none to minimal disability (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.14-1.47) and less likely to be discharged with moderate to severe disability (OR 0.77, 95%CI 0.67-0.87) compared with those in the delayed treatment group. The in-hospital mortality was higher in the early treatment group compared with the delayed treatment group (OR 1.36 95%CI 1.12-1.66).nnnCONCLUSIONnPatients with SAH who undergo aneurysm treatment within 48 hours of hospital admission are more likely to be discharged with none to minimal disability. Early treatment is more likely to occur in those undergoing endovascular treatment and in patients admitted on weekdays.

The new standard for performance of intracranial angioplasty and stent placement after Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) Trial.

Percutaneous transluminal angioplasty and stent placement (PTAS) has become a treatment option for selected patients with symptomatic intracranial arterial stenosis.[1][1] The Stent Placement versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS)

Periprocedural Management of Patients on Dabigatran Etexilate Treatment

Dabigatran etexilate is a direct thrombin inhibitor that was initially introduced for oral anticoagulation for the prevention or treatment of venous thrombosis.[1][1] After the recently concluded phase III trial Randomized Evaluation of Long-Term Anticoagulation Therapy,[2][2] dabigatran has been

Induced hypertension in patients with partial recanalization after intra-arterial thrombolysis for acute ischemic stroke.

Contrast Microscopic examination (Nikon Eclipse 80i, Nikon Corporation, Japan) revealed uniformly particles of size 4 to 6 mm (Fig. 1). We further extended our finding to mixing methylprednisolone with rocuronium bromide, another muscle relaxant commonly used in our department. This time a curdy precipitate was obtained and microscopic examination revealed particulate size of 6 to 8 mm (Fig. 2). The incompatibility of rocuronium with methylprednisolone was confirmed from recommendations by manufacturers. However, the incompatibility of vecuronium with methylprednisolone could not be found. As the particle size of precipitate from vecuronium bromide is <6 mm its clinical significance is uncertain. It is known that the particles larger than 6 mm may produce embolization in lungs. However, the possibility of altered drug potency with this incompatibility cannot be ruled out. Our observation suggests that neither infusions of vecuronium bromide or rocuronium bromide should be coadministered with methylprednisolone through the same intravenous line. We recommend administering these drugs separately through different intravenous lines. Hemanshu Prabhakar, MD* Zulfiqar Ali, MD* Girija P. Rath, MD, DM* Ishfaq A. Sheikh, MScw Departments of *Neuroanaesthesiology wBiophysics All India Institute of Medical Sciences New Delhi, India

Acute Reversal of Clopidogrel-Related Platelet Inhibition Using Methyl Prednisolone in a Patient with Intracranial Hemorrhage

Clopidogrel and ticlopidine are agents that irreversibly inhibit adenosine diphosphate (ADP)–induced platelet aggregation.[1][1] Interaction of ADP with the P2Y1 receptor of the platelet induces platelet shape change, reversible aggregation, initial glycoprotein IIb/IIIa activation, phospholipase

Intra-arterial etomidate for provocative testing in embolization procedure for cerebral arteriovenous malformation.

REFERENCES 1. Morrison LJ, Neumar RW, Zimmerman JL, et al. Strategies for improving survival after inhospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association. Circulation. 2013;127:1538–1563. 2. Rinehart TW, Merkel MJ, Schulman PM, et al. Therapeutic hypothermia after perioperative cardiac arrest in cardiac surgical patients. ICU Dir. 2012;3:271–278.

Response to Letter Regarding Article, “Non-ST-Segment–Elevation Myocardial Infarction in Patients Undergoing Carotid Endarterectomy or Carotid Artery Stent Placement”

We agree with Filis et al1 that in total, further investigation of the incidence and management of perioperative myocardial infarction (MI) after carotid endarterectomy (CEA) or carotid artery stent (CAS) is needed. However, it is important to avoid conflation of asymptomatic perioperative MI with isolated perioperative cardiac marker elevation in this context. Although the former represents either type I or type II MI according to the third universal definition for MI,2 the latter may instead be a function of pre-existing disease processes such as chronic kidney disease or congestive heart failure. Such comorbidities are frequently present in patients who …

Response to journal club: Factors and outcomes associated with early and delayed aneurysm treatment in subarachnoid hemorrhage patients in the United States.

T hank you for allowing us the opportunity to respond to the Journal Club article “Journal Club: Factors and Outcomes Associated with Early and Delayed Aneurysm Treatment in Subarachnoid Hemorrhage Patients in the United States.” The authors have very carefully reviewed our publication and raised some important concerns. Here, we provide explanations that may be helpful in the interpretation of our results. Our study was based on the Nationwide Inpatient Sample (NIS) database from 2005 to 2008 and included 32 048 patients during the study period. This is a study of a large database and is subject to several limitations that apply to any such large database study. NIS-based studies look at the trends of different medical treatments and aspects of their outcomes in a community outside the bias of a funded, controlled, preplanned study. This invariably means that there is a large associated selection bias, along with the complicating effect of the validity of the International Classification of Diseases, ninth edition, clinical modification, coding system. Naturally, a database of such magnitude is made easy to understand, generalized, and standardized as allinclusive medical data; therefore, disease-specific markers, pertinent disease severity indexes, and related outcomes measures are missing. However, the biases introduced by single and multicenter registries and trials that are confounded by selection and referral bias are absent; thus, the results are reflective of medical practice at large. Keeping these issues in mind, we offer our responses to the concerns raised by the reviewers. Section I. The mechanism that underlies the lower rate of disability in patients treated within 48 hours is speculative. Both cerebral vasospasm and rerupture of a ruptured intracranial aneurysm are major contributors to death and disability in patients with subarachnoid hemorrhage. It is reasonable to consider that both cerebral vasospasm and rerupture can be influenced by early treatment and therefore may contribute to observed results. Large observational studies like ours are insufficient to conclusively identify mechanisms of death and disability. Section II. In the International Cooperative Study, early treatment was defined as 0 to 3 days, and 5.7% of patients suffered rerupture of a ruptured intracranial aneurysm by day 3. To reduce the rate of pretreatment rupture, early treatment categorized as 0 to 2 days is more likely to be practical and to affect patient outcome. The widespread availability of endovascular treatment increases the odds of early treatment, as was seen in the International Subarachnoid Aneurysm Trial. The preprocedural rerupture rate was also lower in the endovascularly treated patients compared with surgically treated patients (7% vs 16%) because of the shorter time to treatment. Lawson et al reported that the time interval between admission and endovascular treatment had no effect on morality or poor outcome in 119 consecutive patients with subarachnoid hemorrhage. Baltsavias et al reported similar results in a slightly larger number of patients who were treated within 24 hours of arrival unless medically unstable. Fifteen percent of patients (49 of 327) suffered rebleeding. Of these, 18 patients had poor World Federation of Neurological Societies grades before treatment, and the effect of rebleeding was not clearly described in the article. They did not find a significant correlation between this group and poor outcomes at 6 months. These results are derived from tertiary care center reports, and the small sample size in each study was unlikely to identify small differences. Our study provides an analysis involving a large number of patients adequate to detect both small and large differences. The results are less likely to be influenced by management strategies unique to some centers. Sections III and IV. We have attempted to present the shortcomings of our study on the basis Farhan Siddiq

Response to the Letter by Tariq

I read with interest the article by Tariq et al in the Journal that details outcomes with thrombolytic therapy for acute ischemic stroke in over 1000 dialysis patients. They are to be commended for examining this important aspect of acute stroke care in dialysis cohorts. However, in their discussion, the authors state that a previous US study by Sozio et al reported a 30-day mortality rate of 35% after thrombolysis. This is inaccurate and can potentially cause confusion. In fact, careful review of the article reveals that the authors of that study do not report any thrombolysis-related outcomes and that this mortality rate is for all stroke types (hemorrhagic and ischemic) in the CHOICE (Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Study) cohort. Indeed, the median time from symptom onset to presentation was 11 hours (interquartile range 1-48 hours), suggesting that a significant proportion of patients would have been ineligible for thrombolytic therapy. The reasons for significantly higher rates of pneumonia, deep venous thrombosis, and sepsis in dialysis patients that underpin the high mortality rate of 22% reported in this study require further elucidation. Furthermore, the safety and efficacy of thrombolytic therapy for acute stroke in dialysis patients remain relatively understudied and a topic of great interest for nephrologists and neurologists alike. Yours sincerely,