Jeffrey M. Katz

The Safety and Efficacy of Thrombolysis for Strokes After Cardiac Catheterization

OBJECTIVESnThe purpose of this study was to systematically compare clinical outcomes of patients treated with thrombolysis with those without treatment in a multi-year, multicenter cohort of strokes after cardiac catheterization.nnnBACKGROUNDnIschemic strokes after cardiac catheterization procedures, although uncommon, lead to the morbidity and mortality of thousands of patients each year. Despite the availability of Food and Drug Administration-approved thrombolytic therapy for acute ischemic stroke since 1996, thrombolysis remains unestablished in the setting of cardiac catheterization, owing to unique concerns regarding safety and efficacy.nnnMETHODSnConsecutive cases of ischemic stroke after cardiac catheterization were abstracted retrospectively and reviewed by clinicians at 7 major North American academic centers with acute stroke teams. Safety and efficacy outcome measures were pre-defined.nnnRESULTSnA total of 66 cases of ischemic strokes after cardiac catheterization were identified over 3 to 4 years; 12 (18%) were treated with thrombolysis, consisting of 7 intravenous and 5 intra-arterial recombinant tissue plasminogen activator cases. Improvement in stroke symptoms, as measured by the primary efficacy measure of median change in National Institutes of Health Stroke Scale score from baseline to 24 h, was greater in treated versus nontreated cases (p < 0.001). Additional secondary measures of efficacy also showed better outcomes in the treated group. There were no significant differences in bleeding events, defined as symptomatic intracerebral hemorrhage, hemopericardium, or other systemic bleeding resulting in hemodynamic instability or blood transfusions. Mortality rates were also similar.nnnCONCLUSIONSnThrombolysis might improve early outcomes after post-catheterization strokes and seems safe in this context. Emergent cerebral revascularization should be a routine consideration.

Original ArticleStroke Chameleons

BACKGROUNDnMany conditions called stroke mimics may resemble acute stroke. The converse of the stroke mimic is a presentation suggestive of another condition, which actually represents stroke. These would be stroke chameleons. The recognition of a chameleon as stroke has implications for therapy and quality of care.nnnMETHODSnWe performed a retrospective chart review, including all cases for 1 year in which patients had a stroke missed on hospital presentation. Initial erroneous diagnoses were compared for all patients correctly admitted with those diagnoses to determine positive predictive value (PPV) for each chameleon.nnnRESULTSnNinety-four cases were identified as chameleons where brain imaging revealed acute stroke. The common chameleons were initially diagnosed as altered mental status (AMS) (29, 31%), syncope (15, 16%), hypertensive emergency (12, 13%), systemic infection (10, 11%), and suspected acute coronary syndrome (ACS) (9, 10%). The total number of patients who were diagnosed with these conditions over the same year were AMS (393), syncope (326), hypertensive emergency (144), systemic infection (753), and suspected ACS (817) (total N = 2528). For each chameleon diagnosis, the PPV of each presentation for acute stroke was AMS (7%), syncope (4%), hypertensive emergency (8%), systemic infection (1%), and suspected ACS (1%).nnnCONCLUSIONSnStroke chameleons may result in patients not receiving appropriate care. The largest proportions of chameleons were AMS, syncope, hypertensive emergency, systemic infection, and suspected ACS. Patients diagnosed with hypertensive emergency or AMS had an 8% and 7% chance of having an acute stroke. Physicians should consider stroke in patients with these diagnoses with a lower threshold to obtain neuroimaging with subsequent appropriate management.

Treatment of a giant vertebrobasilar artery aneurysm using stent grafts

This 65-year-old man presented to the authors institution reporting neck swelling. Stage IIIA Hodgkin disease was diagnosed, and a computed tomography scan of the neck revealed a vertebrobasilar artery aneurysm. His medical history was significant for subarachnoid hemorrhage and coma 2 years earlier. Subsequent digital subtraction angiography demonstrated a giant fusiform vertebrobasilar junction aneurysm with associated basilar artery (BA) fenestration. Endovascular treatment of the giant aneurysm was performed by left vertebral artery (VA) occlusion and placement of two Jo-stent coronary stent grafts from the right VA to the BA. The postprocedure course was uneventful. Follow-up angiography performed 1 week postoperatively demonstrated complete exclusion of the aneurysm. This unique case is described and a review of the relevant literature is presented.

Should thrombolysis be given to a stroke patient refusing therapy due to profound anosognosia

We read the article by Katz and Segal with interest.1 We agree that anosognosia due to acute stroke is common and can cause difficulty in the consent process. If the patient fails to perceive that a stroke has occurred, declining treatment is reasonable. We do not believe, however, that this refusal necessarily obviates the option of thrombolysis.nnValid consent requires “adequate decision-making capacity,” including the ability to understand pertinent information regarding her/his condition, to process that information, and to express a decision.2 A person with anosognosia has limited capacity to provide valid consent because of the inability to recognize deficits. At our institution and many others offering thrombolysis as …

Transient aphasia and reversible major depression due to a giant sagittal sinus dural AV fistula

A 61-year-old man presenting with transient global aphasia and chronic major depression was found to have a giant high flow dural arteriovenous fistula of the superior sagittal sinus. EEG and SPECT scan showed left frontoparietal dysfunction. This resolved after fistula embolization, as did the patient’s neuropsychiatric complaints.

Use and Outcomes of Intravenous Thrombolysis for Acute Ischemic Stroke in Patients ≥90 Years of Age

Background and Purpose— Intravenous tissue-type plasminogen activator (tPA) is a proven treatment for acute ischemic stroke, but there has been limited evaluation among patients aged ≥90 years. Methods— We analyzed data from the Get With The Guidelines–Stroke national quality improvement registry from January 2009 to April 2013. Frequency, determinants, and outcomes of tPA use were compared among patients aged ≥90 and 3 younger age groups (18–64, 65–79, and 80–89 years). Results— Among 35u2009708 patients from 1178 sites who arrived within 2 hours of time last known well and received tPA, 2585 (7.2%) were ≥90 years. Compared with younger patients, the rate of tPA use among patients without a documented contraindication was lower among patients aged ≥90 years (67.4% versus 84.1% in 18–89-year olds; P<0.0001). Discharge outcomes among individuals aged ≥90 years included discharge to home or acute rehabilitation in 31.4%, independent ambulation at discharge in 13.4%, symptomatic hemorrhage in 6.1%, and in-hospital mortality or hospice discharge in 36.4%. On multivariable analysis, good functional outcomes generally occurred less often and mortality more often among patients aged ≥90 years. The risk of symptomatic hemorrhage was increased compared with patients <65 years but was not significantly different than the risk in 66- to 89-year olds. Conclusions— The use of intravenous tPA among those aged ≥90 years is lower than in younger patients. When fibrinolytic therapy is used, the risk of symptomatic hemorrhage is not higher than in 66- to 89-year olds; however, mortality is higher and functional outcomes are lower.

Thrombolysis for Ischemic Stroke during Pregnancy: A Case Report and Review of the Literature

BACKGROUND AND PURPOSEnOur knowledge of the safety of thrombolytic therapy in pregnancy stems from individual case reports and series. We report the successful use of intravenous alteplase (tissue plasminogen activator; tPA) thrombolysis in a pregnant woman with acute cardioembolic stroke presumed to be paradoxical embolism through a patent foramen ovale.nnnMETHODSnA literature review found several case reports and case series of pregnant patients treated with either intravenous or intra-arterial tPA for acute ischemic stroke.nnnRESULTSnA literature review yielded 10 cases of intravenous tPA administration and 5 cases of intra-arterial tPA. In total, there were 3 cases of asymptomatic intracerebral hemorrhage and 1 case of maternal and fetal death.nnnCONCLUSIONSnOur patient improved clinically with no residual deficits. There was no evidence of placental or fetal injury following administration of tPA on follow-up obstetrical evaluations.

Prevalence and Risk Factors for Paroxysmal Atrial Fibrillation and Flutter Detection after Cryptogenic Ischemic Stroke

INTRODUCTIONnLong-term cardiac monitoring with implantable loop recorders (ILRs) has revealed occult paroxysmal atrial fibrillation and flutter (PAF) in a substantial minority of cryptogenic ischemic stroke (CIS) patients. Herein, we aim to define the prevalence, clinical relevance, and risk factors for PAF detection following early poststroke ILR implantation.nnnMATERIALS AND METHODSnA retrospective study of CIS patients (nu2009=u2009100, mean age 65.8 years; 52.5% female) who underwent ILR insertion during, or soon after, index stroke admission. Patients were prospectively followed by the study cardiac electrophysiologist who confirmed the PAF diagnosis. Univariate and multivariate analyses compared clinical, laboratory, cardiac, and imaging variables between PAF patients and non-PAF patients.nnnRESULTSnPAF was detected in 31 of 100 (31%) CIS patients, and anticoagulation was initiated in almost all (30 of 31, 96.8%). Factors associated with PAF detection include older age (mean [year] 72.9 versus 62.9; Pu2009=u2009.003), white race (odds ratio [OR], 4.5; confidence interval [CI], 1.8-10.8; Pu2009=u2009.001), prolonged PR interval (PRu2009>u2009175u2009ms; OR, 3.3; CI, 1.2-9.4; Pu2009=u2009.022), larger left atrial (LA) diameter (mean [cm] 3.7 versus 3.5; Pu2009=u2009.044) and LA volume index (mean [cc/m2]; 30.6 versus 24.2; Pu2009=u2009.014), and lower hemoglobin (Hb)A1c (mean [%] 6.0 versus 6.4; Pu2009=u2009.036). Controlling for age, obesity (body mass indexu2009>u200930u2009kg/m2; OR, 1.2; CI, 1.1-1.4; Pu2009=u2009.033) was independently associated with PAF detection.nnnDISCUSSIONnPAF was detected with high prevalence following early postcryptogenic stroke ILR implantation and resulted in significant management changes. Older age, increased PR interval, LA enlargement, and lower HbA1c are significantly associated with PAF detection. Controlling for age, obesity is an independent risk factor. A larger prospective study is warranted to confirm these findings.

Improving Transfer Times for Acute Ischemic Stroke Patients to a Comprehensive Stroke Center

BACKGROUND AND OBJECTIVEnThe transfer of acute ischemic stroke (AIS) patients to a comprehensive stroke center (CSC) must be rapid. Delays pose an obstacle to time-sensitive stroke treatments and, therefore, increase the likelihood of exclusion from endovascular stroke therapy. This study aims to evaluate the impact of the Stroke Rescue Program, with its goal of minimizing interfacility transfer delays and increasing the number of transport times completed within 60 minutes.nnnMETHODSnThe Stroke Rescue Program was initiated to facilitate the rapid transfer of AIS patients from regional primary stroke centers (PSCs) to the networks CSC. The transfer process was divided into 3 time elements: transport 1 time (initial phone call from the PSC until emergency medical service [EMS] arrival at the PSC), emergency department (ED) time (EMS PSC arrival to PSC departure), and transport 2 time (PSC departure to CSC arrival). The total transport time target was set at less than 60 minutes. Protocols and procedures were implemented with a focus on decreasing the ED time.nnnRESULTSnComparing baseline (preimplementation) quarter (nu2009=u200921) to postproject quarter (1 year later, nu2009=u200931), the percent transported within 60 minutes increased from 62% to 81%. A statistically significant improvement was seen for both median ED time (23 minutes versus 14 minutes; Uu2009=u2009171, Pu2009<u2009.01) and median total transport time (56 minutes versus 44 minutes; Uu2009=u2009199, Pu2009<u2009.05).nnnCONCLUSIONnInterfacility transfer protocols minimizing the time paramedics spend in a PSC ED can significantly reduce total transfer time to a comprehensive stroke center.

Poor Hypertension Control and Longer Transport Times Are Associated with Worse Outcome in Drip-and-Ship Stroke Patients

BACKGROUNDnThe drip-and-ship paradigm is an important treatment modality for acute ischemic stroke (AIS) patients who do not have immediate access to a comprehensive stroke center (CSC). Intravenous thrombolysis is initiated at a primary stroke center followed by expeditious transfer to a CSC. We sought to determine factors associated with poor outcomes in drip-and-ship AIS patients transferred to a CSC.nnnMETHODSnThis study is a retrospective analysis of 130 consecutive drip-and-ship patients transferred by ambulance to a single CSC between July 2012 and June 2014. Multiple patient and transport factors were analyzed. Transport blood pressure (BP) control was considered inadequate if the systolic BP was greater than 180u2009mmHg and/or diastolic BP was greater than 105u2009mmHg upon CSC arrival. Poor patient outcome was defined as discharge to hospice or expiry, a discharge modified Rankin Scale (mRS) score higher than 2, or symptomatic intracerebral hemorrhage (ICH).nnnRESULTSnThere was a significant association between inadequate BP control upon CSC arrival and in-hospital mortality or discharge to hospice (Pu2009<u2009.0007). Arrival BP was not associated with the risk of post-thrombolysis symptomatic ICH. Longer transport time was significantly associated with a poorer mRS score at discharge (Pu2009<u2009.0174) and death (Pu2009<u2009.0351).nnnCONCLUSIONSnPost-thrombolysis BP guideline violations and longer transport times during drip-and-ship transfers were significantly associated with poor outcome. Guidelines for strict transport BP management and alternative modes of transfer for longer-distance transports may be warranted.