Anjail Sharrief

Predictors of critical care needs after IV thrombolysis for acute ischemic stroke.

Background and Purpose Intravenous (IV) tissue plasminogen activator (tPA) is the only Food and Drug Administration (FDA)-approved treatment for acute ischemic stroke. Post tPA patients are typically monitored in an intensive care unit (ICU) for at least 24 hours. However, rigorous evidence to support this practice is lacking. This study evaluates factors that predict ICU needs after IV thrombolysis. Methods A retrospective chart review was performed for 153 patients who received intravenous tPA for acute ischemic stroke. Data on stroke risk factors, physiologic parameters on presentation, and stroke severity were collected. The timing and nature of an intensive care intervention, if needed, was recorded. Using multivariable logistic regression, we determined factors associated with requiring ICU care. Results African American race (Odds Ratio [OR] 8.05, 95% Confidence Interval [CI] 2.65–24.48), systolic blood pressure, and National Institutes of Health Stroke Scale (NIHSS) (OR 1.20 per point increase, 95% CI 1.09–1.31) were predictors of utilization of ICU resources. Patients with an NIHSS≥10 had a 7.7 times higher risk of requiring ICU resources compared to patients who presented with an NIHSS<10 (p<0.001). Most patients with ICU needs developed them prior to the end of tPA infusion (81.0%, 95% CI 68.8–93.1). Only 7% of patients without ICU needs by the end of the tPA infusion went on to require ICU care later on. These patients were more likely to have diabetes mellitus and had significantly higher NIHSS compared to patients without further ICU needs (mean NIHSS 17.3, 95% CI 11.5–22.9 vs. 9.2, 95% CI 7.7–9.6). Conclusion Race, NIHSS, and systolic blood pressure predict ICU needs following tPA for acute ischemic stroke. We propose that patients without ICU needs by the end of the tPA infusion might be safely monitored in a non-ICU setting if NIHSS at presentation is low.

Vitamin B(12) deficiency with bilateral globus pallidus abnormalities.

OBJECTIVE To describe a case of vitamin B(12) deficiency with classic and rare clinical features and novel radiographic features. DESIGN Case report. SETTING Johns Hopkins Hospital neurology service. PATIENT Middle-aged man with neuropathy, myelopathy,impaired cognition, and extrapyramidal signs. RESULTS The patient had neurologic and hematologic signs of vitamin B(12) deficiency, with elevated methylmalonic acid and homocysteine levels. Brain magnetic resonance imaging showed signal abnormality in the globi pallidi, as can be seen in inherited methylmalonic acidemia.The clinical and radiographic findings reversed with vitamin B(12) administration. CONCLUSION Vitamin B(12) deficiency can present with extrapyramidal symptoms and reversible bilateral globus pallidus abnormalities.

Stroke Outreach in an Inner City Market: A Platform for Identifying African American Males for Stroke Prevention Interventions

Background There are significant racial disparities in stroke incidence and mortality. Health fairs and outreach programs can be used to increase stroke literacy, but they often fail to reach those at highest risk, including African American males. Methods We conducted a stroke outreach and screening program at an inner city market in order to attract a high-risk group for a stroke education intervention. A modified Framingham risk tool was used to estimate stroke risk and a 10-item quiz was developed to assess stroke literacy among 80 participants. We report results of the demographic and stroke risk analyses and stroke knowledge assessment. Results The program attracted a majority male (70%) and African American (95%) group of participants. Self-reported hypertension (57.5%), tobacco use (40%), and diabetes (23.8%) were prevalent. Knowledge of stroke warning signs, risk factors, and appropriate action to take for stroke symptoms was not poor when compared to the literature. Conclusion Stroke outreach and screening in an inner city public market may be an effective way to target a high-risk population for stroke prevention interventions. Stroke risk among participants was high despite adequate stroke knowledge.

Video-based educational intervention associated with improved stroke literacy, self-efficacy, and patient satisfaction

Background and purpose Interventions are needed to improve stroke literacy among recent stroke survivors. We developed an educational video for patients hospitalized with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH). Methods A 5-minute stroke education video was shown to our AIS and ICH patients admitted from March to June 2015. Demographics and a 5-minute protocol Montreal Cognitive Assessment were also collected. Questions related to stroke knowledge, self-efficacy, and patient satisfaction were answered before, immediately after, and 30 days after the video. Results Among 250 screened, 102 patients consented, and 93 completed the video intervention. There was a significant difference between pre-video median knowledge score of 6 (IQR 4–7) and the post-video score of 7 (IQR 6–8; p<0.001) and between pre-video and the 30 day score of 7 (IQR 5–8; p = 0.04). There was a significant difference between the proportion of patients who were very certain in recognizing symptoms of a stroke pre- and post-video, which was maintained at 30-days (35.5% vs. 53.5%, p = 0.01; 35.5% vs. 54.4%, p = 0.02). The proportion who were “very satisfied” with their education post-video (74.2%) was significantly higher than pre-video (49.5%, p<0.01), and this was maintained at 30 days (75.4%, p<0.01). There was no association between MoCA scores and stroke knowledge acquisition or retention. There was no association between stroke knowledge acquisition and rates of home blood pressure monitoring or primary care provider follow-up. Conclusions An educational video was associated with improved stroke knowledge, self-efficacy in recognizing stroke symptoms, and satisfaction with education in hospitalized stroke patients, which was maintained at 30 days after discharge.

Abstract WP270: Outcomes of Telestroke tPA Patients Who Stay at Community Hospitals vs Transfer to a Comprehensive Stroke Center

Introduction: Telemedicine (TM) is increasingly utilized for tPA delivery. The destination of the patient after tPA, whether to stay at the presenting hospital or transfer to a hub stroke center, i...

Race is a Predictor of Withdrawal of Life Support in Patients with Intracerebral Hemorrhage

INTRODUCTION Medical and socioeconomic factors may impact decisions to change the goals of care for patients with intracerebral hemorrhage (ICH) to comfort measures only. METHODS We reviewed prospectively collected data on patients with ICH, including baseline patient demographics, Glasgow Coma Scale (GCS), National Institute of Health Stroke Scale (NIHSS), and ICH score. We conducted multivariable logistic regression analysis to identify predictors of change to comfort measures only status. RESULTS Of 198 patients included in the analysis, 39 (19.7%) were made comfort measures only. Age, gender, insurance status, substance use, and medical comorbidities were similar between groups. Race was significantly different between the comfort measures only (black 15.4%, white 51.3%, other 33.3%) and noncomfort measures only groups (black 39.6%, white 45.9%, other 14.5%; P = .003). Patients changed to comfort measures only had higher mean income based on zip code (

Predictors of Percutaneous Endoscopic Gastrostomy Placement in Acute Ischemic Stroke

59,264 versus

The Impact of Pre-Stroke Depressive Symptoms, Fatalism, and Social Support on Disability after Stroke

49,916; P = .021), higher median NIHSS (23 versus 16; P = .0001), higher ICH score (2.7 versus 1.5; P < .0001), lower median GCS (7 versus 13; P < .0001). Following multivariable analysis, factors associated with comfort measures only were GCS odds ratio (OR) 0.77, 95% confidence interval (CI) 0.68-0.86, P < .0001), intraventricular hemorrhage (IVH) volume (OR 1.03, 95% CI 1.01-1.06, P = .002), and black race (OR 0.24, 95% CI 0.07-0.82, P = .022). Mortality, poor outcome, and hospital length of stay were not significantly different between black and white patients. CONCLUSIONS Lower GCS score, higher IVH volume, and race were independent predictors of comfort measures only. Black patients were 76% less likely to withdraw life support than white patients. There were no significant differences in mortality between black and white patients. Providers should be aware of potential racial disparities.

Stroke Knowledge in African Americans: A Narrative Review

BACKGROUND Dysphagia is a common complication of stroke and can have a lasting impact on morbidity and mortality; yet there are no standards to guide dysphagia management in stroke patients. We assessed predictors of percutaneous endoscopic gastrostomy (PEG) placement in an ischemic stroke cohort and sought to determine the utility of an objective scale in predicting PEG placement in a high-risk sub-set. METHODS Consecutive cases of ischemic stroke were retrospectively, identified and demographic and clinical variables were collected. Penetration-Aspiration (PAS) scores (1-2 normal; 3-5 penetration; 6-8 aspiration) were calculated for patients undergoing Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Modified Barium Swallowing Studies (MBSS). Multiple logistic regression analysis was used to assess predictors of PEG placement. RESULTS Among 724 patients, 131 underwent PEG placement. In univariate analysis of the overall cohort, sex, age, insured payer status, arrival National Institute of Health Stroke Scale (NIHSS), NIHSS level of consciousness severity, NIHSS dysarthria severity, diabetes mellitus, and prior International Conference for Harmonization (ICH) were all significantly associated with PEG placement. Among 197 high-risk patients undergoing FEES or MBSS, the multivariate logistic regression analysis showed that PAS scores 6-8 versus 1-2 (odds ratio [OR] 13.2; 95% confidence interval [CI] 4.58, 38.2), PAS score 3-5 versus 1.2 (OR 33.8; 95% CI 11.6, 98.3), Hispanic race (OR, 5.73; 95% CI 1.82, 18.0), male sex (OR, 2.59; 95% CI 1.05, 6.34), and arrival NIHSS (OR, 1.11; 95% CI 1.05, 1.18) were associated with PEG placement. CONCLUSIONS Use of an objective dysphagia scale simplified the prediction model among acute ischemic stroke patients undergoing instrumental assessments of dysphagia with FEES or MBSS. Male sex and Hispanic race were also significantly associated with PEG placement in this analysis. These findings support the need for rigorously designed prospective studies to assess biological and social factors that influence PEG placement and to determine, how to best evaluate and manage patients with dysphagia.

Effect of metabotropic glutamate receptor 3 genotype on N-acetylaspartate measures in the dorsolateral prefrontal cortex

BACKGROUND Psychological and social factors have been linked to stroke mortality; however, their impact on stroke disability is unclear. The purpose of this study was to evaluate the impact of pre-stroke fatalism, depressive symptoms, and social support on 90-day neurologic, functional, and cognitive outcomes. METHODS Ischemic strokes (2008-2011) were identified from the Brain Attack Surveillance in Corpus Christi Project. Validated scales were used to assess fatalism, depressive symptoms, and social support during baseline interviews. The National Institutes of Health Stroke Scale, activities of daily living/instrumental activities of daily living (ADL/IADL) scale, and Modified Mini-Mental State Exam (3MSE) were used to assess 90-day outcomes. The associations between the pre-stroke variables and 90-day outcomes were estimated from regression models adjusting for demographics, risk factors, tissue-type plasminogen activator treatment, and comorbidities. RESULTS Among 364 stroke survivors, higher pre-stroke fatalism was associated with worse functional (.17 point higher ADL/IADL per interquartile range [IQR] higher fatalism; 95% confidence interval [CI]: .05, .30) and cognitive (2.81 point lower 3MSE per IQR higher fatalism; 95% CI: .95, 4.67) outcomes. Higher pre-stroke depressive symptoms were associated with worse functional (.16 point higher ADL/IADL per IQR higher Patient Health Questionnaire-9; 95% CI: .04, .28) and cognitive (2.28 point lower 3MSE per IQR higher Patient Health Questionnaire-9; 95% CI: .46, 4.10) outcomes. Participants in the middle tertile of social support had better cognitive outcomes (3.75 points higher 3MSE; 95% CI: .93, 6.56) compared with the highest tertile. CONCLUSIONS The associations between pre-stroke fatalism, depressive symptoms, and social support and 90-day outcomes suggest that psychosocial factors play an important role in stroke recovery.