Aimee Aysenne

Nadir hemoglobin is associated with poor outcome from intracerebral hemorrhage

ObjectiveExamine the relationship between anemia and outcomes from intracerebral hemorrhage (ICH).MethodsPatients admitted with spontaneous ICH between July 2008 and December 2010 were identified from our prospective stroke registry. Patients were divided into two groups based on admission hemoglobin (low vs. normal based on laboratory reference range for gender). Baseline characteristics were compared between groups using Chi-square, t-tests and Wilcoxon Rank Sum tests. Primary outcome was functional status at discharge, with modified Rankin Scale (mRS) 5–6 considered a poor outcome. Cumulative logit and logistic regression models were used to assess the relationships between baseline hemoglobin, nadir hemoglobin, and transfusion with outcomes.ResultsOf the 109 patients, 28% (n = 30) were anemic on admission. Baseline anemia did not predict the primary outcome. Nadir hemoglobin was associated with poor functional outcome at discharge (OR = 1.58, 95% CI 1.31-1.90, p < 0.0001) and remained significant after adjusting for age, baseline NIHSS, transfusion, and length of stay (OR = 1.43, 95% CI 1.06-1.94, p = 0.02). Patients who received a transfusion had 9 times greater odds of having a discharge mRS 5–6 (OR 9.37, 95% CI 2.84-30.88, p = 0.0002) compared with patients who did not receive transfusion. This was no longer statistically significant after adjusting for other factors impacting outcome (OR 4.01, 95% CI 0.64-25.32, p = 0.1392). Neither nadir hemoglobin nor transfusion was found to be independent predictors of in-hospital mortality.ConclusionThis study suggests that nadir hemoglobin, not admission hemoglobin, can be used to predict poor functional outcome. Transfusion was not an independent predictor of poor outcome from ICH.

The Impact of Left Ventricular Hypertrophy and Diastolic Dysfunction on Outcome in Intracerebral Hemorrhage Patients

Background The objective of this study was to determine the prevalence of LVH and DD in patients presenting with supratentorial deep ICH and to determine if the presence of LVH or DD was an independent predictor of initial ICH volume, hematoma expansion, or poor outcome. Methods A cross-sectional study was performed on ICH patients who presented from 7/2008 to 12/2010. Cases were excluded if ICH was traumatic, lobar, infratentorial, secondary to elevated international normalized ratio, suspicious for underlying structural malformation, or where surgical evacuation was performed. Logistic and linear regressions were used to assess the ability of LVH to predict ICH imaging characteristics and patient outcomes. Results After adjusting for use of hemostatic agents, LVH was not a significant independent predictor of initial ICH volume (P = 0.344) or 33% volume expansion (P = 0.378). After adjusting for age, infectious complications, and use of hemostatic agents, LVH was not a significant independent predictor of poor functional outcome (P = 0.778). Similar results were seen for DD. Conclusion In our sample, patients with deep ICH and LVH were more likely to develop IVH, but LVH was not a significant independent predictor of initial ICH volume, hematoma expansion, or poor short-term outcome.

Thrombolysis in Real Time: Demonstration of Revascularization with Intravenous Thrombolysis Therapy in the CT Scanner.

Administration of intravenous tissue plasminogen activator (tPA) in the computed tomography (CT) scanner has been recently implemented at our institution, as a means to decrease door‐to‐needle time. This change in protocol provided us a unique opportunity to visualize imaging signs of early recanalization.

Prolonged Emergency Department Length of Stay as a Predictor of Adverse Outcomes in Patients with Intracranial Hemorrhage

Objectives Extended time in the emergency department (ED) has been related to adverse outcomes among stroke patients. We examined the associations of ED nursing shift change (SC) and length of stay in the ED with outcomes in patients with intracerebral hemorrhage (ICH). Methods Data were collected on all spontaneous ICH patients admitted to our stroke center from 7/1/08–6/30/12. Outcomes (frequency of pneumonia, modified Rankin Scale (mRS) score at discharge, NIHSS score at discharge, and mortality rate) were compared based on shift change experience and length of stay (LOS) dichotomized at 5 hours after arrival. Results Of the 162 patients included, 60 (37.0%) were present in the ED during a SC. The frequency of pneumonia was similar in the two groups. Exposure to an ED SC was not a significant independent predictor of any outcome. LOS in the ED ≥5 hours was a significant independent predictor of discharge mRS 4–6 (OR 3.638, 95% CI 1.531–8.645, and P = 0.0034) and discharge NIHSS (OR 3.049, 95% CI 1.491–6.236, and P = 0.0023) but not death. Conclusions Our study found no association between nursing SC and adverse outcome in patients with ICH but confirms the prior finding of worsened outcome after prolonged length of stay in the ED.

Continuous Qualitative Electroencephalography as a Noninvasive Neuromonitor

Intracranial pressure (ICP) monitoring frequently guides key decisions in the management of diseases causing intracranial hypertension. Although typically measured by invasive means, contraindications may leave the clinician with little recourse for dynamic ICP evaluation—particularly when the patient’s mental status is compromised. We describe here a healthy 18-year-old woman who subacutely progressed to coma due to diffuse cerebral venous sinus thrombosis. Heparinization precluded the use of invasive ICP monitoring, and electroencephalography (EEG) was used novelly as a surrogate ICP monitor. She responded well to anticoagulation and hyperosmolar therapy guided by qualitative EEG and was later discharged with a nearly normal neurologic examination. She was found to have Salmonella bacteremia, heterozygous prothrombin and factor V Leiden mutations, and hemoglobin H disease.

Hepatitis C and recurrent treatment-resistant acute ischemic stroke

Since the introduction of recombinant tissue plasminogen activator and thrombolysis, acute ischemic stroke has become a treatable disorder if the patient presents within the 4.5-hour time window. Typically, sporadic stroke is caused by atherosclerotic disease involving large or small cerebral arteries or secondary to a cardioembolic source often associated with atrial fibrillation. In the over-65-year age group, more rare causes of stroke, such as antiphospholipid syndromes, are unusual; such stroke etiologies are mostly seen in a younger age group (<55 years). Here we describe acute ischemic stroke in three patients >65 years with hepatitis C–associated antiphospholipid antibodies. We suggest that screening for antiphospholipid disorders in the older patient might be warranted, with potential implications for therapeutic management and secondary stroke prevention.