Muhammad Suri

Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team.

Objective:To determine predictors of in-hospital and long-term mortality and length of stay in patients admitted to the neurosciences critical care unit. Design:Retrospective analysis of a prospectively collected database. Setting:Neurosciences critical care unit of a large academic tertiary care hospital. Patients:Adult patients (n = 2381) admitted to our neurosciences critical care unit from January 1997 to April 2000. Interventions:Introduction of a specialized neurocritical care team. Measurements and Main Results:Data obtained from the database included demographics, admission source, length of stay, neurosciences critical care unit and hospital disposition, admission Acute Physiology and Chronic Health Evaluation (APACHE) III score, and principal and secondary diagnoses. The introduction of a neurocritical care team in September 1998 was also collected, as was death at 1 yr after admission. Univariate analysis was carried out using Student’s t-test, Mann-Whitney U test, or chi-square test (significance, p < .05). A logistic regression model was used to create a prediction model for in-hospital and long-term mortality. A general linear model was used to determine predictors of length of stay (after log transformation). Independent predictors of in-hospital mortality included APACHE III (odds ratio, 1.07 [1.06–1.08]) and admission from another intensive care unit (odds ratio, 2.9 [1.4–6.2]). The presence of a neurocritical care team was an independent predictor of decreased mortality (odds ratio, 0.7 [0.5–1.0], p = .044). Admission after the neurocritical care team was implemented was associated with reduced length of stay in both the neurosciences critical care unit (4.2 ± 4.0 vs. 3.7 ± 3.4, p < .001) and the hospital (9.9 ± 8.0 vs. 8.4 ± 6.9, p < .0001). There was no difference in readmission rates to the intensive care unit or discharge disposition to home before and after the neurocritical care team was established. The availability of the neurocritical care team was not associated with significant changes in long-term mortality. Factors independently associated with long-term mortality included female gender, admission from another intensive care unit, APACHE III score, and being moderately disabled before admission. Conclusion:Introduction of a neurocritical care team, including a full-time neurointensivist who coordinated care, was associated with significantly reduced in-hospital mortality and length of stay without changes in readmission rates or long-term mortality.

Predictors of Hyperacute Clinical Worsening in Ischemic Stroke Patients Receiving Thrombolytic Therapy

Background and Purpose— Although long-term outcome determinants in acute ischemic stroke (AIS) patients have been defined, less is known about those predicting hyperacute worsening after thrombolytic therapy (TT). We investigated predictors of short-term clinical worsening (National Institutes of Health Stroke Scale [NIHSS] change ≥4 within 24 hours of admission). Methods— We studied 201 AIS patients who received TT within 6 hours of symptom onset. We determined baseline demographics, comorbidities, NIHSS at baseline and at 24 hours after TT, head computed tomography scan before and within 24 hours after TT, and angiographic recanalization in patients treated with intra-arterial (IA) thrombolysis. Significance of relationships was evaluated by t test or Wilcoxon signed rank sum test. Logistic regression model (LRM) was fitted to determine independence of significant variables. Results— Of 201 patients, 13% worsened, 39% improved, and 48% remained unchanged 24 hours after TT. Most patients (72%) received IA thrombolysis. Patients who deteriorated, compared with those who improved, were more likely to have complicating intracranial hemorrhage (ICH; P <0.001), absent recanalization (P =0.026), and higher blood glucose (BG; P =0.049). Hyperglycemia (>150 mg/dL) was greater in patients who worsened even in presence of recanalization (P =0.004, odds ratio [OR] 6.47). LRM showed that adjusted OR for increased risk of bad outcome and mortality for an increase of BG by 50 mg/dL is 1.56 and 1.38, respectively. Conclusions— Hyperglycemia and ICH are independent predictors of hyperacute worsening in AIS patients receiving TT. Although recanalization is the purpose of IA thrombolysis, its impact on clinical improvement may not be apparent without strict BG control.

Rates and predictors of 5-year survival in a national cohort of asymptomatic elderly patients undergoing carotid revascularization.

BACKGROUNDnCurrent American Heart Association guidelines recommend carotid revascularization for asymptomatic patients on the basis of life expectancy.nnnOBJECTIVEnTo determine the rates and predictors of 5-year survival in elderly patients with asymptomatic carotid artery stenosis who underwent either carotid artery stent placement (CAS) or carotid endarterectomy (CEA).nnnMETHODSnThe rates of 5-year survival were determined by use of Kaplan-Meier survival methods in a representative sample of fee-for-service Medicare beneficiaries ≥65 years of age who underwent CAS or CEA for asymptomatic carotid artery stenosis with postprocedural follow-up of 3.4 ± 1.7 years. Cox proportional hazards analysis was used to assess the relative risk of all-cause mortality for patients in the presence of selected comorbidities, including ischemic heart disease, chronic renal failure, and atrial fibrillation, after adjustment for potential confounders such as age, sex, race/ethnicity, and procedure type.nnnRESULTSnA total of 22,177 patients with asymptomatic carotid artery stenosis were treated with either CAS (n = 2144) or CEA (n = 20,033). The overall estimated 5-year survival rate (±SE) was 95.3 ± 0.00149; it was 95.5% and 93.8% in patients treated with CEA and CAS, respectively. After adjustment for potential confounders, relative risk of all-cause 5-year mortality was significantly higher among patients with atrial fibrillation (relative risk, 1.8; 95% confidence interval, 1.5-2.1) and those with chronic renal failure (relative risk, 2.1; 95% confidence interval, 1.7-2.6).nnnCONCLUSIONnRisks and benefits must be carefully weighed before carotid revascularization in elderly patients with asymptomatic carotid artery stenosis who have concurrent atrial fibrillation or chronic renal failure.

Prolonged Microcatheter-Based Local Thrombolytic Infusion as a Salvage Treatment After Failed Endovascular Treatment for Cerebral Venous Thrombosis: A Multicenter Experience

Background and PurposeTo determine the effectiveness of prolonged microcatheter-based local thrombolytic infusion in treatment of patients with cerebral venous thrombosis who achieved no or suboptimal recanalization with transvenous endovascular treatment.MethodsData collection: Prospectively registries supplemented by retrospective review. Settings: Three hospitals with tertiary referral base. Patients: Patients who underwent transvenous endovascular treatment for cerebral venous thrombosis. Intervention: Prolonged microcatheter-based local thrombolytic infusion of alteplase at the rate of 0.5–1xa0mg/h in patients in whom initial angiographic outcome was deemed suboptimal, either due to incomplete or no recanalization.ResultsSerial angiograms were performed to assess treatment response as follows: grade I, partial recanalization of one or more occluded dural sinuses with improved flow or visualization of branches; grade II, complete recanalization of one sinus but persistent occlusion of the other sinuses (A—no residual flow, B—nonocclusive flow); grade III, complete recanalization. Clinical outcome was determined at 1–3 months using modified Rankin scale. A total of 14 patients underwent 15 transvenous endovascular treatments. Initial treatment was considered suboptimal in 12/15 procedures due to no recanalization in five (grade 0), partial recanalization (grade I) in four, complete recanalization of one sinus but persistent occlusion of the other sinuses (grade 2A in two and 2B in one). A prolonged microcatheter-based local recombinant tissue plasminogen activator infusion was used following ten of the 15 procedures for a median duration of 18xa0h (range 13–22 h). Follow-up angiography demonstrated complete recanalization in four procedures and improvement in grades of partial recanalization in six procedures (final grades 2A in three and 2B in three procedures). None of the patients developed new symptomatic intracranial hemorrhage associated with local thrombolytic infusion. At follow-up, patients in five of ten procedures had achieved a modified Rankin scale of 0 and one patient had achieved a score of 1 (no neurological deficits but had residual headaches).ConclusionProlonged microcatheter-based local thrombolytic infusion appeared to be effective treatment in patients who have suboptimal response to acute transvenous endovascular treatment without any additional adverse events.