Claranne Mathiesen

Strokes After Cardiac Surgery and Relationship to Carotid Stenosis

OBJECTIVE To critically examine the role of significant carotid stenosis in the pathogenesis of postoperative stroke following cardiac operations. DESIGN Retrospective cohort study. SETTING Single tertiary care hospital. PARTICIPANTS A total of 4335 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both. MAIN OUTCOME MEASURES Incidence, subtype, and arterial distribution of stroke. RESULTS Clinically definite stroke was detected in 1.8% of patients undergoing cardiac operations during the same admission. Only 5.3% of these strokes were of the large-vessel type, and most strokes (76.3%) occurred without significant carotid stenosis. In 60.0% of cases, strokes identified via computed tomographic head scans were not confined to a single carotid artery territory. According to clinical data, in 94.7% of patients, stroke occurred without direct correlation to significant carotid stenosis. Undergoing combined carotid and cardiac operations increases the risk of postoperative stroke compared with patients with a similar degree of carotid stenosis but who underwent cardiac surgery alone (15.1% vs 0%; P = .004). CONCLUSIONS There is no direct causal relationship between significant carotid stenosis and postoperative stroke in patients undergoing cardiac operations. Combining carotid and cardiac procedures is neither necessary nor effective in reducing postoperative stroke in patients with asymptomatic carotid stenosis.

Pennsylvania comprehensive stroke center collaborative: Statement on the recently updated IV rt-PA prescriber information for acute ischemic stroke.

OBJECTIVE Recently, the FDA guidelines regarding the eligibility of patients with acute ischemic stroke to receive IV rt-PA have been modified and are not in complete accord with the latest AHA/ASA guidelines. The resultant differences may result in discrepancies in patient selection for intravenous thrombolysis. METHODS Several comprehensive stroke centers in the state of Pennsylvania have undertaken a collaborative effort to clarify and unify our own recommendations regarding how to reconcile these different guidelines. RESULTS Seizure at onset of stroke, small previous strokes that are subacute or chronic, multilobar infarct involving more than one third of the middle cerebral artery territory on CT scan, hypoglycemia, minor or rapidly improving symptoms should not be considered as contraindications for intravenous thrombolysis. It is recommended to follow the AHA/ASA guidelines regarding blood pressure management and bleeding diathesis. Patients receiving factor Xa inhibitors and direct thrombin inhibitors within the preceding 48 h should be excluded from receiving IV rt-PA. CT angiography is effective in identifying candidates for endovascular therapy. Consultation with and/or transfer to a comprehensive stroke center should be an option where indicated. Patients should receive IV rt-PA up to 4.5h after the onset of stroke. CONCLUSIONS The process of identifying patients who will benefit the most from IV rt-PA is still evolving. Considering the rapidity with which patients need to be evaluated and treated, it remains imperative that systems of care adopt protocols to quickly gather the necessary data and have access to expert consultation as necessary to facilitate best practices.

Caring for Patients Treated With Therapeutic Hypothermia

Numerous studies have indicated that therapeutic hypothermia can improve neurological outcomes after cardiac arrest. This treatment has redefined care after resuscitation and offers an aggressive intervention that may mitigate postresuscitation syndrome. Caregivers at Lehigh Valley Health Network, Allentown, Pennsylvania, an academic, community Magnet hospital, treated more than 200 patients with therapeutic hypothermia during an 8-year period. An interprofessional team within the hospital developed, implemented, and refined a clinical practice guideline for therapeutic hypothermia. In their experience, beyond a protocol, 5 critical elements of success (interprofessional stakeholders, coordination of care delivery, education, interprofessional case analysis, and participation in a global database) enhanced translation into clinical practice.

Therapeutic medical hypothermia--a multispecialty approach.

Cardiac arrest remains one of the most common causes of death in developed countries. Those who survive may have significant neurologic morbidity. In the current decade, therapeutic medical hypothermia (TMH) has emerged as the only treatment that unequivocally improves neurologic outcomes in post ventricular fibrillation / ventricular tachycardia induced cardiac arrest. The role of TMH in other forms of cardiac arrest continues to evolve. We present the current status of medical hypothermia, recent patents and recent advances of this evolving therapy.

An Educational Intervention Allows for Greater Prehospital Recognition of Acute Stroke.

We performed a study to determine whether a brief educational intervention directed at pre-hospital providers would increase the identification of stroke victims in the pre-hospital setting. The purpose of this IRB approved, before-and-after research project was to determine whether the implementation of Advanced Stroke Life Support Class (ASLS) [1] training for pre-hospital providers would lead to improved field identification of stroke. In June 2014 we presented a didactic and scenario-based 8 h class teaching the Miami Emergency Neurologic Deficit, (MEND) exam [2] as part of the ASLS class which emphasizes the pre-hospital recognition and management of acute stroke to the 25 full-time and 15 part-time paramedics at a local ambulance service with approximately 16,000,911 calls/year. The receiving hospital is a 900-bed suburban teaching hospital with a yearly census of 80,000 and is a JCAHO approved comprehensive Stroke Center. The course consists of lectures, hands on instruction, and small group stations, which included standardized patients mimicking specific stroke syndromes. At each station, the participants were required to complete a patient assessment, identify the stroke syndrome (left brain, right brain, brainstem, cerebellum