Ann K. Helms

Hyperbaric Oxygen Therapy of Cerebral Ischemia

Background: Hyperbaric oxygen (HBO) therapy of cerebral ischemia has been evaluated in a number of human and animal studies; however, there is presently no consensus on its efficacy. Methods: We present a review of animal and human studies on HBO therapy of cerebral ischemia as well as present potential mechanisms of action of HBO. Results: Animal studies of HBO have shown promise by reducing infarct size and improving neurologic outcome. HBO has also been shown to inhibit inflammation and apoptosis after cerebral ischemia. Early reports in humans also suggested benefit in stroke patients treated with HBO. Recent randomized, controlled human studies, however, have not shown benefit, although all were limited by small sample size. Important differences between animal and human studies suggest HBO might be more effective in stroke within the first few hours and at a pressure of 2–3 ATA. Conclusions: The clinical usefulness of HBO in the treatment of cerebral ischemia is not yet certain. Attention to emerging pathophysiologic data should be taken into consideration in design of any future clinical trials of HBO in acute ischemic stroke.

Clipping or coiling of ruptured cerebral aneurysms and shunt-dependent hydrocephalus

BackgroundHydrocephalus may develop either early in the course of aneurysmal subarachnoid hemorrhage (SAH) or after the first 2 weeks. Because the amount of SAH is a predictor of hydrocephalus, the two available aneurysmal treatments, clipping or coiling, may lead to differences in the need for cerebrospinal fluid (CSF) diversion, as only surgery permits clot removal.MethodsHospital and University Hospitals Consortium (UHC) databases were used to retrieve data on all patients admitted to our hospital with aneurysmal SAH during the last 4 years. The incidence of permanent ventricular shunt (VS) according to treatment modality used was evaluated.ResultsOne hundred eighty-eight patients were admitted with aneurysmal SAH. Coiling was performed on 48 (26%) and clipping on 135 (73.8%) patients. Fifty-six (31%) patients required CSF diversion. External ventricular drain was placed in 30 (22.2%) clipped and 13 (27.1%) coiled patients (p=0.5), and VS in 6 patients of the two treatment groups (4.4 versus 12.5%, respectively; p=0.08). Patients requiring VS had longer UHC-expected hospital length of stay (LOS), as well as observed ICU and hospital LOS, compared to patients with temporary or no CSF diversion (24±14 versus 15±8, 20.5±9 versus 11±7, and 30±13 versus 16±11 days, respectively; p≤0.01). In a logistic regression model, VS was independently associated with rebleeding, external ventricular drain placement, coiling, and UHC-expected LOS (odds ratios, 95% confidence interval 12.1, 2.3–62.6, 6.9, 1.6–30, 6.25, 1.3–29, and 1.1, 1.02–1.14, respectively).ConclusionsOne-third of patients admitted with aneurysmal SAH require temporary or permanent CSF diversion. Permanent shunting was found to be associated with coiling in our patient population.

First Trimester Stroke Prophylaxis in Pregnant Women With a History of Stroke

Background and Purpose— Current recommendations for stroke prevention during early pregnancy in women with a prior stroke history are based on limited evidence. In view of the uncertainty involved in balancing the fetal risk of medication against the maternal risk of recurrent stroke, a substantial variation in clinical decision making was anticipated. Thus, a survey was performed to describe the current practices of U.S. neurologists with a particular interest in stroke with regards to treatment of such patients. Methods— A survey was sent to 384 actively practicing U.S. members of the American Academy of Neurology Stroke and Vascular Neurology section asking what antithrombotic, if any, they would use during first trimester pregnancy in women with a prior history of stroke, either unrelated or related to a previous pregnancy. Results— 230 practitioners responded. Some form of antithrombotic therapy was selected by 75% of practitioners for women with a history of prior stroke not related to pregnancy and by 88% of practitioners for women with a history of prior stroke related to pregnancy. Aspirin and low molecular weight heparin were chosen by 51% and 7%, respectively, for stroke unrelated to pregnancy and by 41% and 25%, respectively, for stroke related to pregnancy. Conclusions— Most practitioners agree that women with a history of stroke should receive prophylaxis during the first trimester. However, much disagreement exists regarding which drug(s) to use. A national registry would be the most practical method of obtaining maternal and fetal outcome data to guide practice in this setting.

Standardized protocols increase organ and tissue donation rates in the neurocritical care unit

The authors tested the effect of uncoupling and removal of the treating physician from organ and tissue donation requests on consent rates for donation in the neurocritical care unit. After a neurointensivist-led policy change, consent rates increased from 23.1 to 36.5% (odds ratio = 1.9, p = 0.01), whereas there was no change in other hospital units. This supports such a policy change and shows a positive effect of a neurointensivist on organ and tissue procurement.

One specialty at a time: achieving competency in geriatrics through an e-learning neurology clerkship module.

Background E-learning integrated into traditional clerkships may supplement gaps in medical student training, such as geriatrics competencies. Method An e-module, “Neurology and Dementia: Psychosocial Aspects of Care,” was offered during the M3 Neurology clerkship. OSCE scores were compared between students who did and did not complete the e-module with written examination scores as control. Results Students who completed the e-module had significantly higher scores on the standardized patient (SP) evaluation, written note, and attention to psychosocial aspects of care (P < .05 for all). Exam scores were unaffected (P = .24). Students delaying the OSCE by four weeks still showed retention of this learning. Conclusions An e-module addressing geriatrics core competencies presented during a neurology rotation resulted in sustained learning of these vital concepts.

Hyperbaric Oxygen Therapy of Acute Ischemic Stroke

To the Editor: We read with interest the review article by Hankey et al.1 In an attempt to assess the treatment of acute stroke with hyperbaric oxygen (HBO) the authors performed a review of 3 trials. Although we agree with the statement that there is no level I data to support the use of HBO in the treatment of acute ischemic stroke, we would like to emphasize that the trials evaluated by the authors were not adequate to support their conclusion. First, none of these studies actually enrolled patients during what most neurologists would accept as the acute period of ischemic stroke. Two …

Hyperbaric Oxygen for Stroke

The largest body of evidence involving the use of hyperbaric oxygen for neurologic illness is found in the field of cerebral ischemia. At the center of an infarct, blood flow is completely absent, causing neurons to die within a matter of minutes. This area, therefore, may not be amenable to treatment after the start of symptoms. The region of the brain that draws the most interest is the penumbra, where evidence has shown that blood flow is diminished, but not absent. The cells in this region remain viable for a prolonged period, and can be saved if adequate perfusion is restored. The only FDA approved therapies for acute ischemic stroke include tPA, and interventional intra-arterial treatments aimed at restoring blood flow to the ischemic penumbra, but must be used within the first few hours of the onset of symptoms. There is also evidence that a percentage of the cells subjected to prolonged ischemia will inevitably undergo apoptosis, either after prolonged ischemia or due to reperfusion injury in the case of temporary ischemia. As a result, there has been great interest in using HBO2T for the added benefit of its anti-inflammatory and anti-apoptotic properties. There is reasonable evidence from animal studies, involving mice, rats, gerbils, and cats that damage from focal cerebral ischemia is ameliorated after treatment with HBO2T. Several human trials investigating the use of HBO2T for ischemic stroke have also been performed. Most of these lacked controls, as well as uniform standards for inclusion criteria and outcome measurement. There have been three prominent randomized controlled studies that have evaluated HBO2T in ischemic stroke, none of which where able to demonstrate statistically significant benefit. One might conclude from this that HBO2T is an ineffective treatment for ischemic stroke, however, it should be noted that these studies enrolled patients well after the therapeutic window of 6 12 hours suggested by previous animal studies. Additionally, two of the three also used lower doses of HBO2T than was found effective in animal studies. Based on our present understanding of ischemia, one would not expect improvement in measured outcomes under these conditions. It seems therefore reasonable to assess patients presenting for potential HBO2T for a pattern of penumbra as this provides the strongest evidence of recoverable tissue. As the ischemic penumbra represents the area which is expected to be most salvageable, it is reasonable to determine whether a penumbra is or is not present in patients undergoing experimental treatment with HBO2T. On MRI, penumbra is represented by perfusion-diffusion mismatch. More simply stated, we must find the area of brain which is dying in hope that HBO2.T can still save it before it is dead. This is called ischemic penumbra. In the rat model of focal ischemic stroke produced via thrombotic occlusion of the MCA, MRI revealed perfusiondiffusion mismatch which persists up to 6-12 hours after the occlusion. In patients such

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