Robert L. Ruff

Complications of lumbar puncture followed by anticoagulation.

The complications associated with lumbar puncture (LP) were compared in 2 groups of 342 patients. The first group of patients was anticoagulated after the LP, and the second was not. The incidence of minor headache or back pain was similar in the 2 groups (Group 1--62%, Group 2--64%). The anticoagulated patients had a higher incidence of paraparesis (Group 1, 5 patients, Group 2, No patients; p less than .05) and severe back or lumbosacral radicular pain lasting more than 48 hours (Group 1, 18 patients, Group 2, 6 patients; p less than .025). Seven of the anticoagulated patients developed spinal hematomas (5 with paraparesis, 2 with severe back pain). Among the anticoagulated patients the risk of a major complication was increased by a traumatic LP (p less than .001), starting anticoagulation within one hour of the LP (p less than .001), or aspirin treatment at the time of the LP (p less than .001). This study suggests that if LP is done, delaying anticoagulation for at least one hour and avoiding concurrent aspirin therapy may decrease the risk of developing an extraparenchymal spinal hematoma.

Transient ischemic attacks associated with hypotension in hypertensive patients with carotid artery stenosis.

In a group of 132 patients with transient ischemic attacks (TIAs) 7 patients (4 men, 3 women, ages 64 to 81) had TIAs preceded by hypotension. The average fall of mean blood pressure during an attack was 26.4 ± 5.5 mm Hg (SD). Only one of these patients had a TIA which was not preceded by hypotension. This episode occurred during a paroxysm of coughing. All 7 of these patients had hypertension, and cerebral arteriography performed in 4 of the 7 revealed hemodynamically significant carotid artery stenosis. Each of the 4 patients developed hypotension and a TIA after the procedure. Twenty of the other patients bad hypotensive episodes but did not develop focal neurological deficits. None of these patients had carotid artery stenosis. This study suggests that hypertensive patients with carotid artery stenosis may be at risk to develop focal cerebral ischemia during acute hypotensive episodes.

Treatment of spinal epidural metastasis improves patient survival and functional state

ObjectivesTo determine factors affecting the success of radiation therapy (RT) of spinal epidural metastases and patient survival after RT. Design/MethodsOne hundred thirty-nine male veterans with an initial spinal epidural metastases treated with dexamethasone and RT were evaluated prospectively. Patients were followed until death. ResultsAt presentation, 84 patients could walk. After RT, 119 patients walked. The likelihood of regaining ambulation increased if treatment began <12 hours after loss of ambulation and if patients had bladder and bowel function and sacral sensory sparing. Treatment reduced pain levels, and ambulatory patients had less pain compared with nonambulatory patients. Median length of survival was 104 weeks for ambulatory patients and 6 weeks for nonambulatory patients. Mean interval between loss of ambulation and death was 4.0 ± 0.5 weeks. Recurrent spinal epidural metastases occurred in 8.63% of patients. ConclusionsPatients who walked after treatment lived longer, were ambulatory for most of their remaining life, had less pain, and had a lower incidence of depression.

Evaluation of acute cerebral ischemia for anticoagulant therapy Computed tomography or lumbar puncture

Of 217 patients with clinical diagnosis of acute stroke 23% had nonischemic lesions diagnosed by computed tomography (CT) or lumbar puncture (LP). CT demonstrated all 37 cases of intracerebral hemorrhagic lesions; 9 were detected by LP. CT failed to demonstrate 8 of 17 cases of subarachnoid hemorrhage, but only 1 of these lacked headache or stiff neck. In 7 of 342 patients who were treated with anticoagulants after LP, spinal hematoma followed LP (5 with paraparesis). CT evaluation reduced the incidence of fatal cerebral hemorrhage during anticoagulant therapy of acute stroke. However, even if patients were evaluated with both CT and LP, the incidence of fatal cerebral hemorrhage resulting from intravenous anticoagulant therapy was 2.4%.

Environmental reduplication associated with right frontal and parietal lobe injury.

Four patients with environmental reduplication, a specific form of spatial disorientation and confabulation are described. The patients maintained that their hospital rooms were located in their homes. Each patients had evidence of right frontal or right parietal injury based upon computed tomography, neurosurgery, and neuropsychological testing. The factors associated with environmental reduplication were: impaired spatial perception and visual memory, inability of the patients to recognise the inconsistency between their believed location and their actual location, confusion soon after admission to hospital, and a strong desire to be at home.

Formation and Function of Acute Stroke–Ready Hospitals Within a Stroke System of Care Recommendations From the Brain Attack Coalition

Background and Purpose— Many patients with an acute stroke live in areas without ready access to a Primary or Comprehensive Stroke Center. The formation of care facilities that meet the needs of these patients might improve their care and outcomes and guide them and emergency responders to such centers within a stroke system of care. Methods— The Brain Attack Coalition conducted an electronic search of the English medical literature from January 2000 to December 2012 to identify care elements and processes shown to be beneficial for acute stroke care. We used evidence grading and consensus paradigms to synthesize recommendations for Acute Stroke–Ready Hospitals (ASRHs). Results— Several key elements for an ASRH were identified, including acute stroke teams, written care protocols, involvement of emergency medical services and emergency department, and rapid laboratory and neuroimaging testing. Unique aspects include the use of telemedicine, hospital transfer protocols, and drip and ship therapies. Emergent therapies include the use of intravenous tissue-type plasminogen activator and the reversal of coagulopathies. Although many of the care elements are similar to those of a Primary Stroke Center, compliance rates of ≥67% are suggested in recognition of the staffing, logistical, and financial challenges faced by rural facilities. Conclusions— ASRHs will form the foundation for acute stroke care in many settings. Recommended elements of an ASRH build on those proven to improve care and outcomes at Primary Stroke Centers. The ASRH will be a key component for patient care within an evolving stroke system of care.

Experimental cerebral ischemia produced by extracranial vascular injury Protection with indomethacin and prostacyclin

To determine whether the production of brain ischemia is modified by antiplatelet agents administered at the time of extracranial endothelial injury, we modified a four-vessel occlusion rat model so that an electrogenic platelet thrombus in one carotid artery produced cerebral ischemia. DC current was passed through an anode around the left carotid artery of 11 rats with preoccluded vertebral and contralateral carotid arteries. Five of six untreated rats became unresponsive because of carotid occlusion and resultant cerebral ischemia; none of five animals pretreated with indomethacin and infused with prostacyclin (PGI2) were clinically affected. Light-and electronmicroscopic studies showed arterial platelet-fibrin thrombi and ischemic brain damage in untreated rats. All rats had received radiolabeled platelets; radioactivity was increased in the electrogenically injured left carotid arteries from treated and untreated rats, but counts were reduced by more than 80% in indomethacin/ PGL2-treated rats (p < 0.01).

Catatonia with frontal lobe atrophy.

A middleaged woman with a four year history of behavioural change including episodes of catatonia is described. Despite a persistently abnormal electroencephalogram, the patient was diagnosed repeatedly as suffering from a primary psychiatric disorder. Neurological examination and psychological testing suggested frontal lobe dysfunction, which was confirmed by the finding of isolated frontal lobe atrophy on computed axial tomography.