Ramesh Madhavan

Rare sensory and autonomic disturbances associated with vitamin B12 deficiency.

Vitamin B12 deficiency is an important nutritional disorder causing neurological manifestations of myelopathy, neuropathy and dementia. Sub-acute combined degeneration (SCD) with involvement of the posterior columns in the cervical and thoracic cord is a common presentation of this disorder. In this case report, we describe a 43 year old woman with pernicious anemia and myelopathy with atypical clinical features. The patient presented with motor symptoms, a sensory level and bladder dysfunction. She had severe autonomic disturbances including an episode of unexplained bronchospasm, which has not been previously reported as a manifestation of vitamin B12 deficiency. We review the literature regarding these rarely reported features of vitamin B12 deficiency, and discuss aspects of management of this reversible condition. We emphasize the importance of awareness of autonomic disturbances in B12 deficient individuals.

Clinical Profiles, Complications, and Disability in Cocaine-Related Ischemic Stroke

Cocaine use is associated with ischemic stroke through unique mechanisms, including reversible vasospasm, drug-induced arteritis, enhanced platelet aggregation, cardioembolism, and hypertensive surges. To date, no study has described disability in patients with cocaine-related ischemic stroke. The present study compared risk factors, comorbidities, complications, laboratory findings, medications, and outcomes in patients with cocaine-related (n = 41) and non-cocaine-related (n = 221) ischemic stroke (n = 147) and transient ischemic attack (n = 115) in 3 academic hospitals. The patients with cocaine-related stroke were younger (mean age, 51.9 years vs 59.1 years; P = .0008) and more likely to be smokers (95% vs 62.9%; P < .004). The prevalence of arrhythmias was significantly higher in the patients with cocaine-related stroke, and that of diabetes was significantly higher in those with non-cocaine-related strokes. The prevalence of hypertension and lipid profiles were similar in the 2 groups; however, those with cocaine-related stroke were less likely to receive statins. Antiplatelet use was similar in the 2 groups. Survivors of both groups had similar modified Rankin scores and lengths of hospital stay. In the older urban population, smoking and cocaine use may coexist with other cerebrovascular risk factors, and cocaine-related strokes have similar morbidities and mortality as non-cocaine-related strokes. Moreover, because the patients with cocaine-related stroke is younger, they have an earlier morbidity. New strategies for effective stroke prevention interventions are needed in this subgroup.

Why do ischemic stroke and transient ischemic attack patients get readmitted

OBJECTIVE Readmission is an important indicator for the quality of healthcare services. The authors examined the reasons for 30-day readmission among urban stroke patients, and their clinical consequences. METHODS Consecutive patients admitted to a JCAHO certified primary stroke center with ischemic stroke or transient ischemic attacks (TIA) were included. Demographics, TOAST mechanism, risk factors, treatments administered and discharge destination were collected. Charts were reviewed for readmissions up to 30 days from discharge. Reasons for readmission and outcomes in terms of disability and discharge destination were determined. RESULTS Two hundred sixty-five patients (50.9% male; 79.6%African American; mean age 60.9 years) were included. There were 205(77.4%) strokes and 60(22.6%) TIAs. Thirteen (5%) patients died during their first admission. Of the remaining 252 patients, 25 (9.9%) were readmitted within 30 days. The reason for readmission was neurological in 8/25 patients (32%; 3 ischemic strokes, 1 hemorrhagic stroke and 4 TIAs); and non-neurological in 17/25 patients (68%). The frequent non-neurological reasons were infections (6/25), electrolyte disturbances (3/25) and trauma related to falls (2/25). Patients with coronary artery disease were more likely to be readmitted (45.5% vs. 14.7%; p=0.001) An NIH stroke scale ≥10 predicted readmission (50.0% vs. 25.4% for NIHSS<10; p value 0.02). Patients discharged home or to acute rehabilitation units were less likely to be readmitted than those discharged to subacute rehabilitation units or nursing homes (8.2% vs. 23.8%; p value=0.01). INTERPRETATION Disabling strokes are more likely to be readmitted. The reason is often non-neurological, and sometimes preventable. Physicians should review cases that return within 30 days and determine best practices that prevent readmission.

Automated Data Mining: An Innovative and Efficient Web-Based Approach to Maintaining Resident Case Logs

BACKGROUND Use of resident case logs has been considered by the Residency Review Committee for Neurology of the Accreditation Council for Graduate Medical Education (ACGME). OBJECTIVE This study explores the effectiveness of a data-mining program for creating resident logs and compares the results to a manual data-entry system. Other potential applications of data mining to enhancing resident education are also explored. DESIGN/METHODS Patient notes dictated by residents were extracted from the Hospital Information System and analyzed using an unstructured mining program. History, examination and ICD codes were obtained and compared to the existing manual log. The automated data History, examination, and ICD codes were gathered for a 30-day period and compared to manual case logs. RESULTS The automated method extracted all resident dictations with the dates of encounter and transcription. The automated data-miner processed information from all 19 residents, while only 4 residents logged manually. The manual method identified only broad categories of diseases; the major categories were stroke or vascular disorder 53 (27.6%), epilepsy 28 (14.7%), and pain syndromes 26 (13.5%). In the automated method, epilepsy 114 (21.1%), cerebral atherosclerosis 114 (21.1%), and headache 105 (19.4%) were the most frequent primary diagnoses, and headache 89 (16.5%), seizures 94 (17.4%), and low back pain 47 (9%) were the most common chief complaints. More detailed patient information such as tobacco use 227 (42%), alcohol use 205 (38%), and drug use 38 (7%) were extracted by the data-mining method. CONCLUSIONS Manual case logs are time-consuming, provide limited information, and may be unpopular with residents. Data mining is a time-effective tool that may aid in the assessment of resident experience or the ACGME core competencies or in resident clinical research. More study of this method in larger numbers of residency programs is needed.

Higher risk factor burden and worse outcomes in urban carotid endarterectomy patients.

Background and Purpose— Previous multicenter carotid endarterectomy (CEA) studies had screening criteria for patient comorbidities and very few blacks. We assessed the hypothesis that CEA results from two urban hospitals would approximate those of the previous multicenter trials. Methods— A retrospective chart review was completed at two urban hospitals for CEA procedures done in 2003 and 2004. Demographic information and past medical history was recorded. In hospital perioperative complications (stroke or myocardial infarction [MI]) were noted. We calculated an expected perioperative stroke rate based on trial figures and our proportion of symptomatic and asymptomatic patients. Results— Patients in our cohort had significantly higher rates of hypertension, diabetes, smoking, black race, and elderly status compared to previous trials. The expected perioperative stroke was 3.1%, and the observed stroke rate was 4.7% (P=0.36). Observed rates of MI (6.7%, P<0.001)) and stroke or MI (11.3%, P<0.0001) were higher than expected based on the previous trials. The stroke or MI rate in black subjects was higher (15.4% versus 5.6%, P=0.065) and this was significant at the hospital with lower CEA volume. Conclusions— In two urban hospitals, CEA results were significantly worse than previous trials. Patient selection is likely to play a role because our cohort had higher numbers of hypertensives, diabetics, smokers, blacks, and elderly patients. Clinicians need to carefully consider the risk/benefit ratio of CEA in urban patients because our study shows that these patients have a large number of medical comorbidities and worse outcomes after CEA.

Role of Non-High-Density Lipoprotein Cholesterol in Predicting Cerebrovascular Events in Patients Following Myocardial Infarction

Although there appears to be a role for statins in reducing cerebrovascular events, the exact role of different lipid fractions in the etiopathogenesis of cerebrovascular disease (CVD) is not well understood. A secondary analysis of data collected for the placebo arm (n = 2,078) of the Cholesterol and Recurrent Events (CARE) trial was performed. The CARE trial was a placebo-controlled trial aimed at testing the effect of pravastatin on patients after myocardial infarction. Patients with histories of CVD were excluded from the study. A Cox proportional-hazards model was used to evaluate the association between plausible risk factors (including lipid fractions) and risk for first incident CVD in patients after myocardial infarction. At the end of 5 years, 123 patients (6%) had incident CVD after myocardial infarction (76 with stroke and 47 with transient ischemic attack). Baseline non-high-density lipoprotein (HDL) cholesterol level emerged as the only significant lipid risk factor that predicted CVD; low-density lipoprotein cholesterol and HDL cholesterol were not significant. The adjusted hazard ratios (adjusted for age, gender, hypertension, diabetes mellitus, and smoking) for CVD were 1.28 (95% confidence interval [CI] 1.06 to 1.53) for non-HDL cholesterol, 1.14 (95% CI 0.96 to 1.37) for low-density lipoprotein cholesterol, and 0.90 (95% CI 0.75 to 1.09) for HDL cholesterol (per unit SD change of lipid fractions). This relation held true regardless of the level of triglycerides. After adjustment for age and gender, the hazard ratio for the highest natural quartile of non-HDL was 1.76 (95% CI 1.05 to 2.54), compared to 1.36 (95% CI 0.89 to 1.90) for low-density lipoprotein cholesterol. In conclusion, non-HDL cholesterol is the strongest predictor among the lipid risk factors of incident CVD in patients with established coronary heart disease.

Calcific aortic valve and spontaneous embolic stroke: a review of literature.

Aortic valve calcification is common in the elderly and in patients with congenital bicuspid aortic valve but unlike calcific mitral valve disease it is not a well recognized risk factor for stroke. Although autopsy studies have revealed evidence of systemic embolism in one-third of cases with calcific aortic valves, there is conflicting data from larger clinical studies examining the association between calcific aortic valve and stroke. There are only 8 reported cases of symptomatic stroke from spontaneous cerebral thromboembolism associated with calcific aortic valve in the literature. Computerized tomography (CT) angiography and CT without contrast are modalities of choice to diagnose calcific embolism, while MRI may be useful in delineating the extent of ischemia. Ideal management strategy, the role of antiplatelet therapy, anticoagulation or recommendations for valve replacements are poorly defined. We present a focused literature review on this topic.

Early use of MRI improves diagnostic accuracy in young adults with stroke

OBJECTIVES The misdiagnosis of acute ischemic stroke in young adults is a significant problem since patients may have many decades of potential disability. Also, proven therapies for acute stroke may not be administered if there is an initial misdiagnosis. We assessed the hypothesis that early use of MRI, arrival by ambulance, and presentation to a Primary Stroke Center (PSC) would be associated with a reduced rate of misdiagnosis. METHODS A prospective database of young adults (ages 16-49 years) with ischemic stroke (final diagnosis provided by vascular neurologists) was reviewed. We collected information on several variables, including age, race, arrival by ambulance, whether brain MRI was performed within 48 h, and initial presentation to a PSC. Variables were tested against emergency department (ED) misdiagnosis using univariate and multivariate methods. RESULTS 77 patients with a mean age of 37.9 years were reviewed. 48.3% of patients arrived by ambulance, 53.2% had a brain MRI within 48 h, and 23.4% initially presented to a PSC. The overall rate of ED misdiagnosis was 14.5%. In multivariate testing, performance of MRI within 48 h (p=0.023) was associated with a lower rate of misdiagnosis and age <35 years was linked with greater likelihood of misdiagnosis (p=0.047). CONCLUSIONS Early performance of MRI leads to greater accuracy of stroke diagnosis in young adults presenting to the ED. Patients less than age 35 years have a greater risk of misdiagnosis. ED physicians and neurologists should consider early use of MRI in young adults with stroke-like deficits and diagnostic uncertainty.

Predictors of stroke in patients with severe systolic dysfunction in sinus rhythm: Role of echocardiography

BACKGROUND Congestive heart failure in sinus rhythm ranks second after atrial fibrillation (AF) among cardiogenic risk-factors for stroke. Clinical and echocardiographic predictors of stroke in this high-risk population remain poorly defined. METHODS Retrospective screening of 1886 consecutive patients with severe systolic dysfunction (LVEF ≤35%) at a tertiary medical center echocardiography database (Nov 2005-Sep 2008) identified 83 patients in sinus rhythm with cardioembolic stroke. Patients with AF on follow-up, prosthetic valve, ventricular arrhythmia and lack of consensus between reviewing neurologists were excluded (n=10). Consecutive age and gender-matched controls in sinus rhythm formed GpII (n=73). RESULTS The incidence of stroke was 3.9% (73/1886) over 35 months in this study. There were no significant differences in prevalence of established clinical risk-factors for stroke. There was a significantly higher prevalence of LV non-compaction (p=0.02), aneurysm (p<0.01), spontaneous echo-contrast (p<0.01) and pulmonary hypertension (p<0.001) in GpI. CONCLUSIONS LV non-compaction, aneurysm, spontaneous echo-contrast and pulmonary hypertension are associated with an increased risk of stroke. While anticoagulation of these high-risk subgroups appears reasonable, further study in a prospective randomized clinical trial merits consideration.

Comparison of Outcomes of Nonsurgical Spontaneous Intracerebral Hemorrhage Based on Risk Factors and Physician Specialty

BACKGROUND The authors report the effects of patient risk factors and physician specialty on the clinical outcomes of patients with spontaneous intracerebral hemorrhage (ICH), who were treated nonsurgically at 3 academic medical centers. To our knowledge, there is no reported literature on the effect of physician specialty and outcomes (modified Rankin scale [mRS] score, in-hospital death, and hospital length of stay [LOS]). METHODS A new patent pending data-mining method, Healthcare Smart Grid, retrospectively analyzed hospital data for 129 patients with spontaneous ICH admitted to 3 (two university and one community) hospitals in a single metropolitan region and treated nonsurgically. Patients with traumatic hemorrhages and subarachnoid hemorrhages were excluded from the study. Demographic data, clinical presentation, medical risk factors, and hematoma characteristics were tested for associations with 3 outcomes: in-hospital death, mRS score at discharge, and LOS. RESULTS A total of 129 cases were identified in the university (77 cases) and community (52 cases) hospitals during a 20-month period (December 2005-July 2007). The mean age was 64.1 years with 48% being men and 83% being black. The median LOS among survivors was 6 days. LOS was significantly associated with physician specialty (P=.002 for both comparisons: neurologists and neurosurgeons with internists) and hemorrhage volume. Mortality in these patients was 23%. In an adjusted analysis, hemorrhage volume (P < .001) and Glasgow Coma Scale score at admission (P=.001) were significant predictors of in-hospital mortality, whereas physician specialty, number of comorbidities, and other risk factors were not. The median mRS score at discharge was 3. Larger hemorrhage volume tends to predict greater disability (P=.06). CONCLUSIONS LOS for spontaneous nonsurgically treated ICH tends to be the least with admission to specialist services such as neurologists and neurosurgeons. Physician specialties do not seem to influence mRS score or mortality in medically managed spontaneous ICH. Hemorrhage volume has a statistically significant association with death and LOS.