Archana Hinduja

Thrombolysis in Ischemic Stroke Without Arterial Occlusion at Presentation

Background and Purpose— None of the randomized trials of intravenous tissue-type plasminogen activator reported vascular imaging acquired before thrombolysis. Efficacy of tissue-type plasminogen activator in stroke without arterial occlusion on vascular imaging remains unknown and speculative. Methods— We performed a retrospective, multicenter study to collect data of patients who presented to participating centers during a 5-year period with ischemic stroke diagnosed by clinical examination and MRI and with imaging evidence of no vascular occlusion. These patients were divided into 2 groups: those who received thrombolytic therapy and those who did not. Primary outcome measure of the study was excellent clinical outcome defined as modified Rankin Scale of 0 to 1 at 90 days from stroke onset. Secondary outcome measures were good clinical outcome (modified Rankin Scale, 0–2) and perfect outcome (modified Rankin Scale, 0). Safety outcome measures were incidence of symptomatic intracerebral hemorrhage and poor outcome (modified Rankin Scale, 4–6). Results— A total of 256 patients met study criteria, 103 with thrombolysis and 153 without. Logistic regression analysis showed that patients who received thrombolysis had more frequent excellent outcomes with odds ratio of 3.79 (P<0.01). Symptomatic intracerebral hemorrhage was more frequent in thrombolysis group (4.9 versus 0.7%; P=0.04). Thrombolysis led to more frequent excellent outcome in nonlacunar group with odds ratio 4.90 (P<0.01) and more frequent perfect outcome in lacunar group with odds ratio 8.25 (P<0.01). Conclusions— This study provides crucial data that patients with ischemic stroke who do not have visible arterial occlusion at presentation may benefit from thrombolysis.

Hematoma expansion in spontaneous intracerebral hemorrhage: predictors and outcome

Background: Hematoma growth is an independent determinant of outcome in patients with intracerebral hemorrhage (ICH). Predictors of hematoma expansion are poorly defined. Our aim is to determine predictors of hematoma expansion in patients with ICH. Methods: We reviewed our prospective database of patients with ICH between January 2009 and June 2012. Patients were divided into two groups based on the presence or absence of hematoma expansion. Hematoma volume was calculated by thin volumetric cuts using special software. Expansion was defined as 33% increase in hematoma volume over 24 hours. We compared risk factors, laboratory parameters, medications and CT findings between the two groups using Fishers exact test. A multivariate regression analysis was performed to identify predictors of expansion. Results: We identified 200 patients with ICH. On univariate analysis, patients with hematoma expansion were more likely to have Warfarin use (37% vs. 11% p = 0.001), low admission GCS (9 ± 4, 11 ± 4, p = 0.003), intraventricular hemorrhage (IVH) (79% vs. 45% p = 0.002) and hydrocephalus (43% vs. 22% p = 0.032). On multivariate regression analysis, prior Warfarin use (OR = 3.6, 95% CI: 1.3,10.3; p = 0.016) and IVH (OR = 5.7, 95% CI: 1.5,20.9; p = 0.009) were significant predictors of hematoma expansion. The ICU length of stay (8 ± 8 vs. 4 ± 6, p = 0.004), intubation rate (82% vs. 32%, p = 0.034), and hospital mortality (68% vs. 20%, p = < 0.001) were significantly higher among patients with hematoma expansion. Conclusion: Patient with prior Warfarin use and IVHs are at risk of hematoma expansion. Aggressive measures to prevent hematoma growth are important in these patients.

Nosocomial Infections in Patients With Spontaneous Intracerebral Hemorrhage

BACKGROUND Nosocomial infections are frequent complications in patients with intracerebral hemorrhage. OBJECTIVES To determine the prevalence, risk factors, and outcomes of nosocomial infections in patients with intracerebral hemorrhage. METHODS Prospectively collected data on patients with spontaneous intracerebral hemorrhage between January 2009 and June 2012 were retrospectively reviewed. Patients who had nosocomial infection during the hospital stay were compared with patients who did not. Poor outcome was defined as death or discharge to a long-term nursing facility. RESULTS At least 1 nosocomial infection developed in 26% of 202 patients with intracerebral hemorrhage. The most common infections were pneumonia (18%), urinary tract infection (12%), meningitis or ventriculitis (3%), and bacteremia (1%). On univariate analysis, independent predictors of nosocomial infection were intraventricular hemorrhage, hydrocephalus, low score on the Glasgow Coma Scale at admission, hyperglycemia at admission, and treatment with mechanical ventilation. On multivariate regression analysis, the only significant predictor of nosocomial infection was intraventricular hemorrhage (odds ratio, 5.4; 95% CI, 1.2-11.4; P = .02). Patients with nosocomial infection were more likely than those without to require a percutaneous gastrostomy tube (odds ratio, 33.1, 95% CI, 23.3-604.4; P < .001) and to have a longer stay in the intensive care unit or hospital without a significant increase in mortality. Patients with nosocomial pneumonia were also more likely to have a poor outcome (P < .001). CONCLUSION Pneumonia was the most common infection among patients with intracerebral hemorrhage.

ASPECTS is a predictor of favorable CT perfusion in acute ischemic stroke

BACKGROUND AND PURPOSE Computed tomography perfusion (CTP) is used by some stroke centers to stratify stroke patients who may potentially benefit from endovascular treatment. Our aim is to identify predictors of a favorable CTP in acute ischemic stroke patients evaluated within 8h from symptoms onset for possible endovascular treatment. MATERIALS AND METHODS We reviewed records of patients who had CTP studies between August 2010 and September 2012. We included all patients with anterior circulation strokes with evidence of large vessel disease. All patients had CT head and CT angiography head and neck as part of our protocol. Favorable CTP was defined as core infarct size less than one third the middle cerebral artery distribution and penumbra>20% of infarct size. The patients were divided into two groups based on favorable CTP or not. Baseline characteristics, time parameters, laboratory data and radiological data were compared between both groups. For statistical analysis, we used independent and Fishers exact tests and a multivariate logistic regression model. RESULTS During this period, 60 patients met the inclusion criteria. Patients with favorable CTP were likely to be ≥ 80 years (33% vs 9%, P = 0.026), have Alberta Stroke Program early CT score (ASPECTS) > 7 (81% v. 21%, P ≤ 0.001) and lower mean time from symptom onset to CTP (234 ± 91 vs 305 ± 122, P = 0.015). On regression analysis, ASPECTS was the only independent predictor of a favorable CTP (OR = 16.2, CI: 4.3-62.2, P < 0.001). CONCLUSION ASPECT score may be used as a tool to predict a favorable CTP. Larger studies are needed to confirm our findings.

Predictors of poor outcome in patients with posterior reversible encephalopathy syndrome

Purpose: Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that, although characteristically reversible, can be fatal or result in long-term disability in a subset of patients. Our aim was to identify factors associated with poor discharge outcome in PRES patients. Materials and methods: We retrospectively reviewed the clinical and radiological records of all patients with PRES admitted at our tertiary care medical center from 2007 to 2014. They were divided based their modified Rankin Score at discharge and compared for their baseline variables, clinical, laboratory and imaging features. Poor outcome was defined by a modified Rankin scale 2–6 and was subdivided based on the primary mechanism that led to poor outcome. Results: Out of 100 PRES subjects, 36% had poor discharge outcomes. Factors associated with poor outcomes on univariate analysis were history of diabetes mellitus, coma, high Charlson comorbidity index, post-transplantation, autoimmune condition, lack of systolic or diastolic hypertension, elevated blood urea nitrogen and involvement of the corpus callosum. On multivariate analysis, only prior diabetes mellitus odd ratio (OR) = 6.8 (95% CI 1.1–42.1, p = 0.04), corpus callosum involvement (OR = 11.7; 95% CI 2.4–57.4, p = 0.00) were associated with poor outcome. Poor outcome also correlated with increased length of hospital stay (OR = 7.9; 95% CI 1.3–49.7, p = 0.03). Conclusion: Large prospective studies incorporating serial blood glucose values and advanced imaging studies are required to validate these findings.

Analysis of youtube as a source of information for peripheral neuropathy

Introduction: YouTube is an important resource for patients. No study has evaluated the information on peripheral neuropathy disseminated by YouTube videos. In this study, our aim was to perform a systematic review of information on YouTube regarding peripheral neuropathy. Methods: The Web site (www.youtube.com) was searched between September 19 and 21, 2014, for the terms “neuropathy,” “peripheral neuropathy,” “diabetic neuropathy,” “neuropathy causes,” and “neuropathy treatment.” Results: Two hundred videos met the inclusion criteria. Healthcare professionals accounted for almost half of the treatment videos (41 of 92; 44.6%), and most came from chiropractors (18 of 41; 43.9%). Alternative medicine was cited most frequently among the treatment discussions (54 of 145, 37.2%), followed by devices (38 of 145, 26.2%), and pharmacological treatments (23 of 145, 15.9%). Conclusions: Approximately half of the treatment options discussed in the videos were not evidence‐based. Caution should be exercised when YouTube videos are used as a patient resource. Muscle Nerve 53: 27–31, 2016

The effect of admission hyperglycemia in stroke patients treated with thrombolysis.

ABSTRACT Background: Acute hyperglycemia (HG) has been shown to correlate negatively with an outcome in stroke patients, yet the mechanism remains controversial. The aim of our study is to study the immediate and long-term effects of admission HG on outcome in a cohort of stroke patients treated with thrombolytic therapy. Methods: We reviewed the prospective dataset of a statewide telestroke network for the characteristics of 195 patients who received intravenous tissue plasminogen activator via telemedicine during a 27-month period. We compared outcome and improvement rate of patients with and without HG. We defined good outcome as a modified Rankin Scale score ≤ 2 and neurological improvement after thrombolysis as either a decrease in National Institutes of Health Stroke Scale (NIHSS) at 24 hr by 5 points from baseline or an NIHSS of 0 at 24 hr. Results: Thirty-one percent of patients had admission HG (Blood sugar > 144). Patients with admission HG had higher 3-month mortality and poor outcome rates than those without normoglycemia (NG). The improvement rates with thrombolysis, however, were similar between the two groups. Conclusions: Admission HG is associated with poor neurological recovery in patients with an acute stroke despite thrombolytic treatment without having an effect on the clinical response to thrombolytic therapy. Larger studies are needed to confirm this finding.

Post t-PA transfer to hub improves outcome of moderate to severe ischemic stroke patients

Background and Purpose Telemedicine offers rural hospitals the ability to treat acute ischemic stroke on site with intravenous tissue plasminogen activator (t-PA). Most patients are subsequently transferred to a hub hospital with a primary stroke center for post t-PA care. There is little evidence that such transfer is beneficial. The purpose of our study is to determine whether the transfer of patients to hub hospitals is beneficial. Methods We retrospectively analyzed data from our prospectively collected cohort in the AR SAVES (Stroke Assistance through Virtual Emergency Support) telestroke network from November 2008 till January 2012. We compared the outcome of patients who were transferred to a “hub” with those who remained at the “spoke” hospital where thrombolysis took place. We stratified patients according to stroke severity using admission NIHSS scores into two groups: patients with mild stroke (NIHSS <8) and those with moderate to severe stroke (NIHSS ≥8). We defined good outcome as a modified Rankin Scale (mRS) score ≤2. Statistical analysis was performed using Fisher’s exact test, two-tailed, and significance was considered at p < 0.05. Results Out of 894 telestroke consultations, 206 patients received thrombolytic therapy; 134 patients had moderate to severe strokes and 160 patients (78%) were transferred to the hub after thrombolytic therapy. The percentage of patients with good outcome at 3 months was similar between patients transferred to hub and those who stayed at the spoke (61% vs. 55%, p = NS). However, when only patients with moderate to severe strokes were analyzed, patients transferred to the hub were more likely to have good outcomes at three months post t-PA (50% versus 24%, p = 0.026). Conclusions Patients with moderate to severe ischemic strokes who were treated with t-PA in a telestroke network may potentially benefit from expert care at a primary stroke center.

Hypoxic ischemic brain injury following in hospital cardiac arrest - lessons from autopsy.

Hypoxic ischemic brain injury (HIBI) is the most decisive factor in determining the outcome following a cardiac arrest. After an arrest, neuronal death may be early or delayed. The aim of our study is to determine the prevalence and predictors of HIBI on autopsy following an in hospital cardiac arrest. We retrospectively reviewed the medical records of patients who sustained an in hospital cardiorespiratory arrest and underwent autopsy following in hospital mortality at our tertiary care medical center from January 2004-June 2012. These patients were identified from the autopsy registry maintained by the Department of Pathology and were classified into two groups based on the presence or absence of HIBI on autopsy. We compared the baseline demographics, risk factors, total duration of cardiopulmonary resuscitation, number of resuscitative events and survival time between both groups. Multivariate logistic regression analysis was performed to identify predictors of hypoxic ischemic injury following cardiac arrest. Out of 71 patients identified during this study period, 21% had evidence of HIBI on autopsy. On univariate analysis, predictors of HIBI were prolonged hospital stay, prolonged survival time following an arrest and a slight increased trend following multiple resuscitative events. On multivariate analysis, prolonged survival time was the only significant predictor of HIBI. Similar to other prognostication cardiac arrest studies, there were minimal predictors of early neuronal injury even on autopsy.

Predictors of seizures in patients with posterior reversible encephalopathy syndrome

PURPOSE Although seizures are common in patients with posterior reversible encephalopathy syndrome (PRES), epilepsy is rare. Our objective was to identify predictors and impact of seizures in patients with PRES. METHODS A retrospective review of the clinical and radiological parameters of all patients diagnosed with PRES from 2007 to 2014 was performed. Patients were divided into two groups based on the occurrence of PRES-related seizures at presentation or during their hospital course. Univariate and multivariate analyses were performed to determine factors associated with the occurrence of PRES-related seizures. RESULTS Of 100 patients, 70% experienced at least one seizure from PRES. On univariate analysis, the factors associated with seizures were the following: high Charlson comorbidity index (4.16±2.89 vs. 2.87±2.20, p=0.03), systemic malignancy (41.4% vs. 16.7%, p=0.02), occipital lobe involvement (97.1% vs. 83.3%, p=0.02), more lobes involved (4.6±1.48 vs. 3.9±1.32, p=0.03) but less likely in patients with visual disturbances (15.7% vs. 46.7%, p=0.005), and facial droop (12.9% vs. 16.7%, p=0.002). On multivariate analysis, only occipital lobe involvement was significantly (odds ratio: 9.63, 95% CI: 1.45-64.10, p=0.02) associated with the occurrence of PRES-related seizures. Despite the occurrence of seizures, they were less likely to require a nursing home placement upon hospital discharge (odds ratio: 0.17, 95% CI: 0.03-0.91, p=0.04). CONCLUSION We conclude that seizures are common in patients with occipital lobe involvement from PRES.