Jose Torres

Individualized treatment with transcranial direct current stimulation in patients with chronic non-fluent aphasia due to stroke.

While evidence suggests that transcranial direct current stimulation (tDCS) may facilitate language recovery in chronic post-stroke aphasia, individual variability in patient response to different patterns of stimulation remains largely unexplored. We sought to characterize this variability among chronic aphasic individuals, and to explore whether repeated stimulation with an individualized optimal montage could lead to persistent reduction of aphasia severity. In a two-phase study, we first stimulated patients with four active montages (left hemispheric anode or cathode; right hemispheric anode or cathode) and one sham montage (Phase 1). We examined changes in picture naming ability to address (1) variability in response to different montages among our patients, and (2) whether individual patients responded optimally to at least one montage. During Phase 2, subjects who responded in Phase 1 were randomized to receive either real-tDCS or to receive sham stimulation (10 days); patients who were randomized to receive sham stimulation first were then crossed over to receive real-tDCS (10 days). In both phases, 2 mA tDCS was administered for 20 min per real-tDCS sessions and patients performed a picture naming task during stimulation. Patients language ability was re-tested after 2-weeks and 2-months following real and sham tDCS in Phase 2. In Phase 1, despite considerable individual variability, the greatest average improvement was observed after left-cathodal stimulation. Seven out of 12 subjects responded optimally to at least one montage as demonstrated by transient improvement in picture-naming. In Phase 2, aphasia severity improved at 2-weeks and 2-months following real-tDCS but not sham. Despite individual variability with respect to optimal tDCS approach, certain montages result in consistent transient improvement in persons with chronic post-stroke aphasia. This preliminary study supports the notion that individualized tDCS treatment may enhance aphasia recovery in a persistent manner.

Analysis of the treatment of neuromyelitis optica

BACKGROUNDnTreatment options for neuromyelitis optica (NMO) are currently based on small retrospective case series and open label studies, ranging from 10 to 103 patients.nnnOBJECTIVEnTo compare the efficacy and tolerability of azathioprine, cyclophosphamide, mycophenolate, and rituximab in patients with neuromyelitis optica.nnnMETHODSnThis is a retrospective chart review and telephone follow-up study of 71 patients with NMO or NMO spectrum disorder, 54 of whom were treated with the study drugs. We compared adverse events, annualized relapse rates and expanded disability status scales before and after treatment.nnnRESULTSnThe median ARR decreased from 1.17 to 0.25 on rituximab (P<0.01), 0.92 to 0.56 on azathioprine (P=0.475), 1.06 to 0.39 on mycophenolate (P<0.05) and 1.30 to 0.92 on cyclophosphamide (P=0.746). When compared directly to azathioprine, rituximab significantly reduced relapse rates (P=0.021). The median EDSS decreased from 7 to 5 on rituximab (P<0.01) and 7 to 6 on azathioprine (P<0.01), and did not change significantly on mycophenolate (4 to 5; P=0.463) or cyclophosphamide (6.5 to 6.5; P=0.881). Twenty-five percent of patients noted adverse events on rituximab, 36% on azathioprine, 36% on mycophenolate, and 80% on cyclophosphamide.nnnCONCLUSIONnRituximab significantly reduces relapse rates and improves disability while maintaining comparable tolerability to other immunosuppressive treatments for NMO.

Majority of 30-Day Readmissions After Intracerebral Hemorrhage Are Related to Infections

Background and Purpose— Infections are common after intracerebral hemorrhage, but little is known about the risk of serious infection requiring readmission after hospital discharge. Methods— To determine if infections are prevalent in patients readmitted within 30 days of discharge, we performed a retrospective cohort study of patients discharged from nonfederal acute care hospitals in California with a primary diagnosis of intracerebral hemorrhage between 2006 and 2010. We excluded patients who died during the index admission, were discharged against medical advice, or were not California residents. Our main outcome was 30-day unplanned readmission with primary infection–related International Classification of Diseases, Ninth Revision, Clinical Modification code. Results— There were 24u2009540 index intracerebral hemorrhage visits from 2006 to 2010. Unplanned readmissions occurred in 14.5% (n=3550) of index patients. Of 3550 readmissions, 777 (22%) had an infection-related primary diagnosis code. When evaluating primary and all secondary diagnosis codes, infection was associated with 1826 (51%) of readmissions. Other common diagnoses associated with readmission included stroke-related codes (n=840, 23.7%) and aspiration pneumonitis (n=154, 4.3%). The most common infection-related primary diagnosis codes were septicemia (n=420, 11.8%), pneumonia (n=124, 3.5%), urinary tract infection (n=141, 4.0%), and gastrointestinal infection (n=42, 1.2%). Patients with a primary infection–related International Classification of Diseases, Ninth Revision, Clinical Modification code on readmission had higher in-hospital mortality compared with other types of readmission (15.6% versus 8.0%, P<0.001). After controlling for other predictors of mortality, primary infection–related readmissions remained associated with in-hospital mortality (relative risk, 1.7; 95% confidence interval, 1.3–2.2). Conclusions— Infections are associated with a majority of 30-day readmissions after intracerebral hemorrhage and increased mortality. Efforts should be made to reduce infection-related complications after hospital discharge.

Neuroprotection After Major Cardiovascular Surgery

Opinion statementNeurologic injury is a common complication of major cardiovascular procedures including coronary artery bypass graft (CABG) surgery, coronary valve replacement, and aortic aneurysm surgery. However, despite ongoing research in the field of neuroprotection, there are currently few pharmacologic and interventional options to effectively protect the brain and spinal cord in the postoperative period. CSF drainage after aortic surgery currently stands as the only neuroprotective intervention that has been consistently shown to protect the spinal cord from ischemic injury, leading to significantly fewer patients with paraplegia and paraparesis. There is promising but conflicting evidence about the potential benefits of agents such as dexmedetomidine, lidocaine, magnesium, and erythropoietin in preventing postoperative stroke and cognitive dysfunction. Postoperative hypothermia has also been studied in preventing neurologic injury after cardiopulmonary bypass. With the rate of cardiovascular surgeries increasing yearly, further investigations are needed to validate many of these therapies and discover new ways to protect the brain and spinal cord from intraoperative and postoperative injuries in this high-risk population.

Symptomatic Carotid Occlusion Is Frequently Associated With Microembolization

Background and Purpose— Symptomatic carotid artery disease is associated with significant morbidity and mortality. The pathophysiologic mechanisms of cerebral ischemia among patients with carotid occlusion remain underexplored. Methods— We conducted a prospective observational cohort study of patients hospitalized within 7 days of ischemic stroke or transient ischemic attack because of ≥50% carotid artery stenosis or occlusion. Transcranial Doppler emboli detection was performed in the middle cerebral artery ipsilateral to the symptomatic carotid. We describe the prevalence of microembolic signals (MES), characterize infarct topography, and report clinical outcomes at 90 days. Results— Forty-seven patients, 19 with carotid occlusion and 28 with carotid stenosis, had complete transcranial Doppler recordings and were included in the final analysis. MES were present in 38%. There was no difference in MES between those with carotid occlusion (7/19, 37%) compared with stenosis (11/28, 39%; P=0.87). In patients with radiographic evidence of infarction (n=39), 38% had a watershed pattern of infarction, 41% had a nonwatershed pattern, and 21% had a combination. MES were present in 40% of patients with a watershed pattern of infarction. Recurrent cerebral ischemia occurred in 9 patients (19%; 6 with transient ischemic attack, 3 with ischemic stroke). There was no difference in the rate of recurrence in those with compared to those without MES. Conclusions— Cerebral embolization plays an important role in the pathophysiology of ischemia in both carotid occlusion and stenosis, even among patients with watershed infarcts. The role of aggressive antithrombotic and antiplatelet therapy for symptomatic carotid occlusions may warrant further investigation given our findings.

Safety of Endovascular Intervention for Stroke on Therapeutic Anticoagulation: Multicenter Cohort Study and Meta-Analysis

INTRODUCTIONnIntravenous (IV) tissue plasminogen activator (tPA) is contraindicated in therapeutically anti-coagulated patients. Such patients may be considered for endovascular intervention. However, there are limited data on its safety.nnnPATIENTS AND METHODSnWe performed a multicenter retrospective study of patients undergoing endovascular intervention for acute ischemic stroke while on therapeutic anticoagulation. We compared the observed rate of National Institute of Neurological Disorders and Stroke defined symptomatic intracerebral hemorrhage (sICH) with risk-adjusted historical control rates of sICH after IV tPA using weighted averages of the hemorrhage after thrombolysis (HAT) and Multicenter Stroke Survey (MSS) prediction scores. We also performed a metaanalysis of studies assessing risk of sICH with endovascular intervention in patients on anticoagulation.nnnRESULTS AND DISCUSSIONnOf 94 cases, mean age was 73 years and median National Institutes of Health Stroke Scale was 19. Anticoagulation consisted of warfarin (nu2009=u200951), dabigatran (nu2009=u20096), rivaroxaban (nu2009=u200913), apixaban (nu2009=u20091), IV heparin (nu2009=u200919), low molecular weight heparin (nu2009=u20093), and combined warfarin and IV heparin (nu2009=u20093). sICH was seen in 7 patients (7%, 95% confidence interval 4-15), all on warfarin. Predicted sICH rates for the cohort based on HAT and MSS scoring were 12% and 7%, respectively. Meta-analysis of 6 studies showed no significant difference in sICH between patients undergoing endovascular intervention on anticoagulation and comparator groups.nnnCONCLUSIONSnEndovascular intervention in subjects on therapeutic anticoagulation appears reasonably safe, with a sICH rate similar to patients not on anticoagulation receiving IV tPA.

Highest In-Hospital Glucose Measurements are Associated With Neurological Outcomes After Intracerebral Hemorrhage

BACKGROUND AND PURPOSEnThe relationship between in-hospital hyperglycemia and neurological outcome after intracerebral hemorrhage (ICH) is not well studied.nnnMETHODSnWe analyzed the relationships between pre-hospital and hospital variables including highest in-hospital glucose (HIHGLC) and discharge Glasgow Coma Scale (GCS), discharge Modified Rankin Scale (MRS) and 3-month MRS using a single-institution cohort of ICH patients between 2013 and 2015.nnnRESULTSnThere were 106 patients in our sample. Mean HIHGLC was 154 ± 58 mg/dL for patients with discharge GCS of 15 and 180 ± 57 mg/dL for patients with GCS < 15; 146 ± 55 mg/dL for patients with discharge MRS 0-3 and 175 ± 58 mg/dL for patients with discharge MRS 4-6; and 149 ± 52 mg/dL for patients with 3-month MRS of 0-3 and 166 ± 61 mg/dL for patients with 3-month MRS of 4-6. On univariate analysis, discharge GCS was associated with HIHGLC (Pu202f=u202f.01), age (Pu202f=u202f.006), ICH volume (Pu202f=u202f.008), and length of stay (LOS) (Pu202f=u202f.01); discharge MRS was associated with HIHGLC (P < .001), age (P < .001), premorbid MRS (Pu202f=u202f.046), ICH volume (P < .001), and LOS (P < .001); and 3-month MRS was associated with HIHGLC (Pu202f=u202f.006), discharge MRS (P < .001), age (Pu202f=u202f.001), sex (Pu202f=u202f.002), ICH volume (Pu202f=u202f.03), and length of stay (Pu202f=u202f.004). On multivariate analysis, discharge GCS only had a significant relationship with ICH volume (odds ratio [OR] .949, .927-.971); discharge MRS had a significant relationship with age (OR 1.043, 1.009-1.079), premorbid MRS (OR 2.622, 1.144-6.011), and ICH volume (OR 1.047, 1.003-1.093); and 3-month MRS only had a significant relationship with age (OR 1.039, 1.010-1.069).nnnCONCLUSIONSnThe relationship between in-hospital hyperglycemia and neurological outcomes in ICH patients was meaningful on univariate, but not multivariate, analysis. Glucose control after ICH is important.