James S. McKinney

Statin Therapy and the Risk of Intracerebral Hemorrhage: A Meta-Analysis of 31 Randomized Controlled Trials

Background and Purpose— Statin therapy decreases the risk of ischemic stroke. An increased risk of intracerebral hemorrhage (ICH) has been observed in some studies. To investigate this issue, we performed a meta-analysis of randomized controlled trials using statins that reported ICH. Methods— We performed a literature search of Medline, Web of Science, and The Cochrane Library through January 25, 2012, and identified additional randomized controlled trials by reviewing reference lists of retrieved studies and prior meta-analyses. All randomized controlled trials of statin therapy that reported ICH or hemorrhagic stroke were included. The primary outcome variable was ICH. Thirty-one randomized controlled trials were included. All analyses used random effects models and heterogeneity was not observed in any of the analyses. Results— A total of 91 588 subjects were included in the active group and 91 215 in the control group. There was no significant difference in incidence of ICH observed in the active treatment group versus control (OR, 1.08; 95% CI, 0.88–1.32; P=0.47). ICH risk was not related to the degree of low-density lipoprotein reduction or achieved low-density lipoprotein cholesterol. Total stroke (OR, 0.84; 95% CI, 0.78–0.91; P<0.0001) and all-cause mortality (OR, 0.92; CI, 0.87–0.96; P=0.0007) were significantly reduced in the active therapy group. There was no evidence of publication bias. Conclusions— Active statin therapy was not associated with significant increase in ICH in this meta-analysis of 31 randomized controlled trials of statin therapy. A significant reduction in all stroke and all-cause mortality was observed with statin therapy.

Comprehensive Stroke Centers Overcome the Weekend Versus Weekday Gap in Stroke Treatment and Mortality

Background and Purpose— Hospital staffing may be reduced on weekends. Prior studies of weekend disparities in stroke care have focused on in-hospital mortality with variable results. We hypothesized that 90-day mortality was higher in patients with stroke hospitalized on weekends versus weekdays, and this difference has been minimized over time by improvements in organization and delivery of stroke care. Methods— We used the Myocardial Infarction Data Acquisition System administrative database, which includes data on patients discharged with a primary diagnosis of cerebral infarction from all nonfederal acute care hospitals in New Jersey between 1996 and 2007. Out-of-hospital deaths were assessed by matching MIDAS records with New Jersey death registration files. New Jersey hospitals are designated by the state as comprehensive stroke centers, primary stroke centers, or nonstroke centers. The primary outcome measure was 90-day all-cause mortality after hospital admission. Results— A total of 134 441 patients were admitted with a primary diagnosis of cerebral infarction during the study period. A total of 23.4% were admitted to a comprehensive stroke center, 51.5% to a primary stroke center, and 25.1% to a nonstroke center. Ninety-day mortality was greater in patients with stroke admitted on weekends compared with weekdays (17.2% versus 16.5%; P=0.002). The adjusted risk of death at 90 days was significantly greater for weekend admission (hazard ratio, 1.05; 95% CI, 1.02 to 1.09). No difference in 90-day mortality was observed for patients admitted to comprehensive stroke centers on weekends versus weekdays (hazard ratio, 1.01; 95% CI, 0.95 to 1.08). Conclusions— Patients with stroke admitted on weekends to New Jersey hospitals had a significantly higher risk of death by 90 days. No such difference in mortality was observed at comprehensive stroke centers.

Hospital Prenotification of Stroke Patients by Emergency Medical Services Improves Stroke Time Targets

BACKGROUND Prenotification to hospitals by emergency medical services of patients with suspected stroke is recommended to reduce delays in time-dependent therapies. We hypothesized that hospital prenotification would reduce recommended stroke time targets. METHODS We used the Robert Wood Johnson University Hospital (RWJUH) Brain Attack Database, which includes demographic and clinical data on all emergency department (ED) patients alerted as a Brain Attack between January 1, 2009 and June 30, 2010. Outcome variables included the time from door to stroke team arrival, computed tomographic (CT) scan completion, CT scan interpretation, electrocardiogram, laboratory results, treatment decision, and intravenous (IV) tissue plasminogen activator (tPA) administration. The primary independent variable was brain attack activation before arrival to the emergency department (ED; prenotification) versus on or after ED arrival (no prenotification). Analysis of covariance was used with patient predictors as covariates in addition to the one of interest (prenotification vs no prenotification). P ≤ .05 was considered statistically significant. RESULTS There were 229 patients (114 prenotification and 115 no prenotification) alerted as having a brain attack within the study period. Patients with prehospital notification were older (69.5 years vs 61.5 years; P = .0002), had more severe strokes (National Institutes of Health Stroke Scale score of 11.1 vs 6.9; P < .0001), and received IV tPA twice as often (27% vs 15%; P = .024). Prenotification resulted in a significant reduction in all stroke time targets except door to treatment decision and tPA administration. CONCLUSIONS Prehospital notification of suspected stroke patients reduces time to stroke team arrival, CT scan completion, and CT scan interpretation. IV thrombolysis occurred twice as often in the prenotification group.

Comprehensive Stroke Centers May Be Associated With Improved Survival in Hemorrhagic Stroke

Background Comprehensive stroke centers (CSCs) provide a full spectrum of neurological and neurosurgical services to treat complex stroke patients. CSCs have been shown to improve clinical outcomes and mitigate disparities in ischemic stroke patients. It is believed that CSCs also improve outcomes in hemorrhagic stroke. Methods and Results We used the Myocardial Infarction Data Acquisition System (MIDAS) database, which includes data on patients discharged with a primary diagnosis of intracerebral hemorrhage (ICH; International Classification of Diseases, Ninth Revision [ICD-9] 431) and subarachnoid hemorrhage (SAH; ICD-9 430) from all nonfederal acute care hospitals in New Jersey (NJ) between 1996 and 2012. Out-of-hospital deaths were assessed by matching MIDAS records with NJ death registration files. The primary outcome variable was 90-day all-cause mortality. The primary independent variable was CSC versus primary stroke center (PSC) and nonstroke center (NSC) admission. Multivariate logistic models were used to measure the effects of available covariates. Overall, 36 981 patients were admitted with a primary diagnosis of ICH or SAH during the study period, of which 40% were admitted to a CSC. Patients admitted to CSCs were more likely to have neurosurgical or endovascular interventions than those admitted to a PSC/NSC (18.9% vs. 4.7%; P<0.0001). CSC admission was associated with lower adjusted 90-day mortality (35.0% vs. 40.3%; odds ratio, 0.93; 95% confidence interval, 0.89 to 0.97) for hemorrhagic stroke. This was particularly true for those admitted with SAH. Conclusions Hemorrhagic stroke patients admitted to CSCs are more likely to receive neurosurgical and endovascular treatments and be alive at 90 days than patients admitted to other hospitals.

Reversible Cerebral Vasoconstriction Syndrome: A Review of Recent Research

Reversible cerebral vasoconstriction syndrome (RCVS) is a collective term used for transient noninflammatory, nonatherosclerotic segmental constriction of cerebral arteries. The angiopathies of RCVS have previously been defined by several nomenclatures. Current opinion favors the unification of these pathophysiologically related angiopathies because of their similar angiographic features and clinical course. RCVS typically presents acutely as headache, delirium, seizure, cerebral ischemia, and/or hemorrhage. The angiographic features make RCVS an important mimic of CNS vasculitides. In contrast to CNS vasculitis, RCVS is typically a transient condition with relatively good clinical outcomes. Although a complete understanding of the etiological and pathological features of RCVS has not yet been achieved, alterations in vascular tone lead to the observed arterial changes. In this review, we aim to provide a summary of RCVS and provide insight into current perspectives of the underlying pathophysiological processes, diagnosis, and treatment.

Intracranial vertebrobasilar artery dissection associated with postpartum angiopathy.

Background. Cervicocephalic arterial dissection (CCAD) is rare in the postpartum period. To our knowledge this is the first reported case of postpartum angiopathy (PPA) presenting with ischemic stroke due to intracranial arterial dissection. Case. A 41-year-old woman presented with blurred vision, headache, and generalized seizures 5 days after delivering twins. She was treated with magnesium for eclampsia. MRI identified multiple posterior circulation infarcts. Angiography identified a complex dissection extending from both intradural vertebral arteries, through the basilar artery, and into both posterior cerebral arteries. Multiple segments of arterial dilatation and narrowing consistent with PPA were present. Xenon enhanced CT (Xe-CT) showed reduced regional cerebral blood flow that is improved with elevation in blood pressure. Conclusion. Intracranial vertebrobasilar dissection causing stroke is a rare complication of pregnancy. Eclampsia and PPA may play a role in its pathogenesis. Blood pressure management may be tailored using quantitative blood flow studies, such as Xe-CT.

Safety of Thrombolytic Therapy for Acute Ischemic Stroke after Recent Transient Ischemic Attack

BACKGROUND The objective of this study was to assess the rate of symptomatic intracerebral hemorrhage (SICH) in patients given thrombolytic therapy for acute ischemic stroke (AIS) after recent transient ischemic attack (TIA). METHODS This was a multicenter study of patients with confirmed TIA within 7 days before an AIS that was treated with intravenous (IV), intra-arterial (IA), or mechanical thrombolysis. A total of 23 cases were identified. RESULTS The median time interval between index TIA and AIS was 9 hours. The median National Institutes of Health Stroke Scale score at the time of AIS was 12. The median time interval between stroke onset and thrombolytic treatment was 90 minutes. Thrombolytic therapies included IV thrombolysis (70%), IA thrombolysis (17%), IA and mechanical thrombolysis (9%), and IV followed by IA and mechanical thrombolysis (4%). The rate of postthrombolysis SICH in this group was 8.6% (2/23). CONCLUSIONS The rate of SICH in our cohort appears similar to overall postthrombolysis hemorrhage rates.

Noninflammatory Cerebral Vasculopathy Associated with Recurrent Ischemic Strokes

Recurrent ischemic strokes often have uncommon causes in young adults. Vascular abnormalities may be considered as a possible etiology. We report a 36-year-old man who experienced recurrent cryptogenic ischemic strokes despite medical therapy. Conventional cerebral angiography was unrevealing. Subsequent brain biopsy revealed a distinctive histopathological pattern of abnormal perivascular collagen deposition without inflammation. Recurrent cryptogenic strokes may have novel etiologies, and brain biopsy should be considered when standard diagnostic tests fail.

Risk Scores for Predicting Post–thrombolysis Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the most dangerous and dreaded complication of thrombolytic therapy for acute ischemic stroke (AIS). The risk for symptomatic ICH (SICH) after AIS was increased from 0.6 to 6.4% after treatment with recombinant tissue plasminogen activator (rt-PA) compared with placebo in the National Institute of Neurological Disorders and Stroke (NINDS) trial. Despite this increased risk for ICH, treatment with rt-PA was associated with significantly better clinical outcomes at three months and one year after stroke. These results led to approval of rt-PA by the US Food and Drug Administration (FDA) for the treatment of AIS in 1996. Almost two decades after the NINDS trial reported the benefit of thrombolytic therapy, fewer than 5% of stroke patients receive rt-PA despite aggressive community and physician education. While there are several factors limiting its utility, fear surrounding hemorrhagic complications has undoubtedly played a significant role in limiting the clinical use of rt-PA.

Stimulus Sensitive Constant Micro Macro Square-Wave Jerks in a Comatose Patient

Abstract Saccades are generally thought of as being cortically generated and not seen in comatose patients. We describe a patient, comatose secondary to a large intracerebral hemorrhage, who developed constant rhythmic small amplitude square-wave jerks with an intersaccadic interval of 130 ms. Despite the patient’s comatose state the eye movements would stop transiently in response to auditory or tactile stimulation and then quickly regain their previous amplitude. The case suggests that the presence of repetitive saccades in the form of square-wave jerks does not indicate consciousness.