Dushyant Damania

Association of CT Perfusion Parameters with Hemorrhagic Transformation in Acute Ischemic Stroke

Because hemorrhagic transformation affects treatment and patient prognosis, these authors explored whether CT perfusion predicts it. Twenty percent of their subjects developed hemorrhagic transformation and these patients did not differ from controls in terms of age, gender, time to presentation, or comorbidities. Only CBV was found to be lower and predictive of hemorrhagic transformation. BACKGROUND AND PURPOSE: Prediction of hemorrhagic transformation in acute ischemic stroke could help determine treatment and prognostication. With increasing numbers of patients with acute ischemic stroke undergoing multimodal CT imaging, we examined whether CT perfusion could predict hemorrhagic transformation in acute ischemic stroke. MATERIALS AND METHODS: Patients with acute ischemic stroke who underwent CTP scanning within 12 hours of symptom onset were examined. Patients with and without hemorrhagic transformation were defined as cases and controls, respectively, and were matched as to IV rtPA administration and presentation NIHSS score (± 2). Relative mean transit time, relative CBF, and relative CBV values were calculated from CTP maps and normalized to the contralateral side. Receiver operating characteristic analysis curves were created, and threshold values for significant CTP parameters were obtained to predict hemorrhagic transformation. RESULTS: Of 83 patients with acute ischemic stroke, 16 developed hemorrhagic transformation (19.28%). By matching, 38 controls were found for only 14 patients with hemorrhagic transformation. Among the matched patients with hemorrhagic transformation, 13 developed hemorrhagic infarction (6 hemorrhagic infarction 1 and 7 hemorrhagic infarction 2) and 1 developed parenchymal hematoma 2. There was no significant difference between cases and controls with respect to age, sex, time to presentation from symptom onset, and comorbidities. Cases had significantly lower median rCBV (8% lower) compared with controls (11% higher) (P = .009; odds ratio, 1.14 for a 0.1-U decrease in rCBV). There was no difference in median total volume of ischemia, rMTT, and rCBF among cases and controls. The area under the receiver operating characteristic was computed to be 0.83 (standard error, 0.08), with a cutoff point for rCBV of 1.09. CONCLUSIONS: Of the examined CTP parameters, only lower rCBV was found to be significantly associated with a relatively higher chance of hemorrhagic transformation.

Systematic Review of Safety and Cost-Effectiveness of Venous Thromboembolism Prophylaxis Strategies in Patients Undergoing Craniotomy for Brain Tumor

BACKGROUND Studies have evaluated various strategies to prevent venous thromboembolism (VTE) in neuro‐oncology patients, without consensus. OBJECTIVE To perform a systematic review with cost‐effectiveness analysis (CEA) of various prophylaxis strategies in tumor patients undergoing craniotomy to determine the safest and most cost‐effective prophylaxis regimen. METHODS A literature search was conducted for VTE prophylaxis in brain tumor patients. Articles reporting the type of surgery, choice of VTE prophylaxis, and outcomes were included. Safety of prophylaxis strategies was determined by measuring rates of VTE and intracranial hemorrhage. Cost estimates were collected based on institutional data and existing literature. CEA was performed at 30 d after craniotomy, comparing the following strategies: mechanical prophylaxis (MP), low molecular weight heparin with MP (MP+LMWH), and unfractionated heparin with MP (MP+UFH) to prevent symptomatic VTE. All costs were reported in 2016 US dollars. RESULTS A total of 34 studies were reviewed (8 studies evaluated LMWH, 12 for MP, and 7 for UFH individually or in combination; 4 studies used LMWH and UFH preoperatively). Overall probability of VTE was 1.49% (95% confidence interval (CI) 0.42‐3.72) for MP+UFH, 2.72% [95% CI 1.23‐5.15] for MP+LMWH, and 2.59% (95% CI 1.31‐4.58) for MP, which were not statistically significant. Compared to a control of MP alone, the number needed to treat for MP+UFH is 91 and 769 for MP+LMWH. The risk of intracranial hemorrhage was 0.26% (95% CI 0.01‐1.34) for MP, 0.74% (95% CI 0.09‐2.61) for MP+UFH, and 2.72% (95% CI 1.23‐5.15) for MP+LMWH, which were also not statistically significant. Compared to MP, the number needed to harm for MP+UFH was 208 and for MP+LMWH was 41. Fifteen studies were included in the final CEA. The estimated cost of treatment was

Does Prolonged Length of Stay in the Emergency Department Affect Outcome for Stroke Patients

127.47 for MP,

Factors associated with recurrent stroke and recanalization in patients presenting with isolated symptomatic carotid occlusion.

142.20 for MP+UFH, and

64-detector CT angiography within 24 hours after carotid endarterectomy and correlation with postoperative stroke

169.40 for MP+LMWH. The average cost per quality‐adjusted life‐year for different strategies was

717 Career Prospects and Professional Landscape Post-Advanced Endoscopy Fellowship: a Survey Assessing Graduates From 2009-2013

284.14 for MP+UFH,

Patient Selection for Intra-Arterial Therapy in Acute Ischemic Stroke: Concordance between Prior Practice Patterns at Strong Memorial Hospital and Current Evidence from Randomized Clinical Trials (P2.317)

338.39 for MP, and

Sa1502 Outcomes of Endotherapy in Symptomatic Pancreas Divisum: A Single Tertiary Care Center Experience

722.87 for MP+LMWH. CONCLUSION Although MP+LMWH is frequently considered the optimal prophylaxis for VTE risk reduction, our model suggests that MP+UFH is the safest and most cost‐effective measure to balance VTE and hemorrhage risks in brain tumor patients at lower risk of hemorrhage. MP+LMWH may be more effective for patients at higher risk of VTE.

Why are most stroke patients deemed poor candidates for intraaterial therapy? A prospective study (P4.306)

Introduction: Conflicting data exist regarding the association between the length of stay (LOS) of critically ill patients in the emergency department (ED) and their subsequent outcome. However, such patients are an overall heterogeneous group, and we therefore sought to study the association between EDLOS and outcomes in a specific subgroup of critically ill patients, namely those with acute ischemic stroke/transient ischemic attack (AIS/TIA). Methods: This was a retrospective review of adult patients with a discharge diagnosis of AIS/TIA presenting to an ED between July 2009 and February 2010. We collected demographics, EDLOS, arrival stroke severity (National Institutes of Health Stroke Scale - NIHSS), intravenous tissue plasminogen activator (IV tPA) use, functional outcome at discharge, discharge destination and hospital-LOS. We analyzed relationship between EDLOS, outcomes and discharge destination after controlling for confounders. Results: 190 patients were included in the cohort. Median EDLOS was 332 minutes (Inter-Quartile Range -IQR: 250.3–557.8). There was a significant inverse linear association between EDLOS and hospital-LOS (p=0.049). Patients who received IV tPA had a shorter median EDLOS (238 minutes, IQR: 194–299) than patients who did not (median: 387 minutes, IQR: 285–588 minutes; p<0.0001). There was no significant association between EDLOS and poor outcome (p=0.40), discharge destination (p=0.20), or death (p=0.44). This remained true even after controlling for IV tPA use, NIHSS and hospital-LOS; and did not change even when analysis was restricted to AIS patients alone. Conclusion: There was no significant association between prolonged EDLOS and outcome for AIS/TIA patients at our institution. We therefore suggest that EDLOS alone is an insufficient indicator of stroke care in the ED, and that the ED can provide appropriate acute care for AIS/TIA patients. [West J Emerg Med. 2014;15(3):267–275.]

Posterior versus anterior circulation strokes: differences at a community level. (P4.312)

Patients with symptomatic internal carotid artery (ICA) occlusion constitute a small proportion of stroke/transient ischaemic attack patients who are at increased risk of early stroke recurrence and poor outcome. The optimal medical treatment for patients with symptomatic ICA occlusion who are ineligible for thrombolysis or thrombectomy is unknown.