Mohammed Rehman

A significant temporal and quantitative relationship exists between high-density lipoprotein levels and acute ischemic stroke presentation

BACKGROUND Reduced serum high-density lipoprotein (HDL-C) is an independent risk factor for ischemic stroke in elderly men. The temporal and quantitative relationships between HDL-C and acute ischemic stroke have not been defined. METHODS We identified patients with first ever acute ischemic stroke presenting to our hospital between 2003 and 2006. Patients with serum fasting lipid levels drawn within 24 h of admission and at least one follow-up visit with a neurologist in our hospital were included. Clinical and laboratory data before, immediately after, and several weeks after the index stroke were collected. RESULTS 191 patients were included (47% women, mean age 62 years). The mean time interval between pre-stroke lipid data and index stroke was 5.2 months; 50% of these patients were taking a statin medication. The mean time interval between index stroke and follow-up lipid testing was 2.6 months. Immediately after the index stroke, HDL-C levels decreased by 18% (p<0.001) relative to pre-stroke levels. This phenomenon was independent of stroke severity, and was blunted among patients with a prior history of myocardial infarction (p<0.01). HDL-C levels increased to pre-stroke levels within 3 months post-stroke. CONCLUSIONS HDL-C levels decrease significantly at the time of acute ischemic stroke. Prior history of myocardial infarction diminishes HDL-C depression at the time of stroke. HDL-C may be an acute phase reactant or nascent biomarker of acute stroke susceptibility. Further prospective studies are needed.

Clevidipine for acute hypertension in patients with subarachnoid hemorrhage: a pilot study

Purpose: Clevidipine is a novel, ultra-short acting dihydropyridine. We hypothesized that clevidipine would rapidly control elevated blood pressure (BP) in patients with aneurysmal subarachnoid hemorrhage (SAH). Materials and Methods: This prospective open-label pilot study evaluated the efficacy and safety of clevidipine in reducing blood pressure (BP) to a pre-specified range and within 30 min before or after clipping or coiling of the aneurysm. Results: We enrolled five patients who received eight clevidipine infusions, including 1587 systolic or diastolic BP data points. The mean SBP upper and lower goals were set at 154 and 122 mmHg. The primary end point of achieving SBP control within <30 min was reached in all patients within 14.2 ± 6.4 min at an infusion rate of 10.8 ± 9.1 mg/h. The mean pre-infusion, during infusion and post-infusion SBP measurements were 165.5 ± 2.55, 146.4 ± 2.48 and 159.3 ± 11.5 mmHg ( p < 0.05 for pre- vs infusion comparison), respectively. After reaching the primary end point and during the clevidipine infusion, 17.5% and 11.8% of SBP readings were above the upper and below the lower goals, respectively. No patients re-bled. In one patient, the infusion had to be stopped temporarily three times due to SBP decrease below the lower goal. Conclusion: Clevidipine controlled SBP in all patients with aneurysmal SAH in <22 min and kept it within the elective range 70% of the time without major complications.

Vancomycin-resistant enterococcal meningitis treated with intrathecal streptomycin

Enterococcal meningitis is a rare complication of neurosurgical procedures. We present a patient who developed vancomycin-resistant enterococcal ventriculitis - meningitis after a brain tumor resection and ventriculoperitoneal shunt placement, treated successfully with intrathecal streptomycin through bilateral cerebrospinal fluid drainage catheters in addition to systemic antibiotics. This is the first report of such treatment for this resistant organism.

Antithrombotic Management of Stroke Patients Before Colonoscopy

BACKGROUND Uncertainty exists regarding the management of antithrombotic medications in ischemic stroke and transient ischemic attack (TIA) patients around the time of colonoscopy. We sought to evaluate whether there was a difference in adverse events among patients who continued medications and those who had temporary discontinuation. METHODS Using a hospital administrative database, electronic charts of patients with a diagnostic code for stroke or TIA and a procedural code for colonoscopy were reviewed. Information collected included baseline demographics, medical history, and antithrombotic medications. Outcome measures were stroke (ischemic and hemorrhagic), myocardial infarction, venous thromboembolism, and major systemic bleeding (i.e., requiring transfusion) up to 4 weeks after the procedure among patients who had medications continued versus temporarily discontinued. RESULTS One hundred seventy-seven patients met inclusion criteria. Antithrombotic medication was temporarily discontinued in 42 patients and continued in 135 patients. Comparing patients who had medications held to those who had medications continued, stroke occurred in 1 (2.4%) versus 0 (0%; P = .237) patients; myocardial infarction in no patients in either group; venous thromboembolism in 0 (0%) versus 1 (0.7%; P > .99) patients; and major system bleeding in 2 (4.8%) versus 4 (3.0%; P = .628) patients. CONCLUSIONS In this retrospective analysis, there was no significant difference in the occurrence of stroke, myocardial infarction, venous thromboembolism, and major bleeding between patients who had medications continued around the time of colonoscopy versus those who had temporary discontinuation. A prospective, randomized controlled study is warranted to further elucidate this issue.

Infection or Inflammation and Critical Care Seizures

Central nervous system (CNS) infections and inflammatory disease are frequent causes of seizures in the intensive care unit (ICU). Given the high incidence of seizures in these disease states, early recognition and treatment can improve patient outcomes, and should be suspected early in the course of evaluation and treatment. Specific infectious causes of encephalitis such as Herpes Simplex Virus (HSV) and Japanese Encephalitis (JE) can present with seizures in up to 34% and 28% of patients, respectively. An infectious etiology is identified in at least 18% of cases of new onset refractory status epilepticus (NORSE). Additionally, there are frequent electroencephalogram (EEG) findings that are characteristic of certain infections, such as lateralized periodic discharges in HSV infections. In some diseases, such as JE, the EEG can also be used as an additional tool to aid in prognosis. Given that many viral and inflammatory illnesses that affect the CNS have no specific treatment, the management of comorbid seizures may be one of the few targets that can effectively improve outcomes.

Hemodynamic and neuro-monitoring for neurocritically ill patients: An international survey of intensivists

Purpose: To investigate multimodality systemic and neuro‐monitoring practices in acute brain injury (ABI) and to analyze differences among “neurointensivists” (NI; clinical practice comprised >1/3 by neurocritical care), and other intensivists (OI). Methods: Anonymous 22‐question Web‐based survey among physician members of SCCM and ESICM. Results: Six hundred fifty‐five responded (66% completion rate); 422 (65%) were OI, and 226 (35%) were NI. More NI follow hemodynamic protocols for TBI (44.5% vs 33%, P = .007) and SAH (38% vs 21%, P < .001). For CPP optimization, NI use more arterial‐waveform‐analysis (AWA) (45% vs 35%, P = .019), and ultrasound (37.5% vs 28%, P = .023); NI use more PbtO2 (28% vs 10%, P < .001). In the case scenario of raised ICP/low PbtO2, most employ analgesia and/or sedation (47%) and osmotherapy (38%). More NI use pressure reactivity (vasopressor use OI 23% vs NI 34.5%, P = .014). For DCI, more NI target cardiac index (CI) (35% vs 21%, P < .001), and fluid responsiveness (62.5% vs 53%, P = .03). Also, NI use more angiography (57% vs 43.5%, P = .004), TCD (56.5% vs 38%, P < .001), CTP (32% vs16%, P < .001), and PbtO2 (18% vs 7.5%, P = .001). Conclusions: Intensivists with exposure to ABI patients employ more neuro‐ and hemodynamic monitoring. We found large heterogeneity and low overall use of advanced brain‐physiology parameters. HighlightsThe overall use of multimodality neuromonitoring is low.Physicians make limited efforts to individualize physiological targets.Intensivists with exposure to acute brain injury tend to employ more monitoring.Further research is needed to define the practical utility of these parameters.

Infection or Inflammation and ICU Seizures

Effective treatment of seizures associated with central nervous system (CNS) infection and inflammation depends on rapid diagnosis and early attainment of bactericidal activity in the cerebrospinal fluid with appropriate antimicrobial agents, or appropriate management of vasculitis-induced cerebral complications. Despite the rarity of these disorders, there is nothing specific regarding the management in the intensive care unit of seizures in these situations, except for a high suspicion by the medical staff. Improvement in long-term neurologic outcome depends on both therapy of the infectious/inflammatory process and the intensive care multisystem monitoring commonly warranted in this patient population. The primary goal of preserving CNS function is shared by the neurologist and the intensivist, making a multidisciplinary approach essential.