Sandeep P. Khot

Do-Not-Attempt-Resuscitation Orders and Prognostic Models for Intraparenchymal Hemorrhage

Objectives:Statistical models predicting outcome after intraparenchymal hemorrhage include patients irrespective of do-not-attempt-resuscitation orders. We built a model to explore how the inclusion of patients with do-not-attempt-resuscitation orders affects intraparenchymal hemorrhage prognostic models. Design:Retrospective, observational cohort study from May 2001 until September 2003. Setting:University-affiliated tertiary referral hospital in Seattle, WA. Patients:Four hundred twenty-four consecutive patients with spontaneous intraparenchymal hemorrhage. Measurements and Main Results:We retrospectively abstracted information from medical records of intraparenchymal hemorrhage patients admitted to a single hospital. Using multivariate logistic regression of presenting clinical characteristics, but not do-not-attempt-resuscitation status, we generated a prognostic score for favorable outcome (defined as moderate disability or better at discharge). We compared observed probability of favorable outcome with that predicted, stratified by do-not-attempt-resuscitation status. We then generated a modified prognostic score using only non-do-not-attempt-resuscitation patients. Records of 424 patients were reviewed: 44% had favorable outcome, 43% had a do-not-attempt-resuscitation order, and 38% died in hospital. The observed and predicted probability of favorable outcome agreed well with all patients taken together. The observed probability of favorable outcome was significantly higher than predicted in non-do-not-attempt-resuscitation patients and significantly lower in do-not-attempt-resuscitation patients. Results were similar when applying a previously published and validated prognostic score. Our modified prognostic score was no longer pessimistic in non-do-not-attempt-resuscitation patients but remained overly optimistic in do-not-attempt-resuscitation patients. Conclusions:Although our prognostic model was well-calibrated when assessing all intraparenchymal hemorrhage patients, predictions were significantly pessimistic in patients without and optimistic in those with do-not-attempt-resuscitation orders. Such pessimism may drive decisions not to attempt resuscitation in patients in whom a favorable outcome may have been possible, thereby creating a self-fulfilling prophecy. To be most useful in clinical decision making, intraparenchymal hemorrhage prognostic models should be calibrated to large intraparenchymal hemorrhage cohorts in whom do-not-attempt-resuscitation orders were not used.

Neurological sequelae of hypoxic-ischemic brain injury

Hypoxic-ischemic brain injury (HI-BI) after cardiac arrest commonly results in neurological injury and long term dysfunction, with outcomes ranging from coma and vegetative states to functional disability with various degrees of dependence. Increased rates of bystander CPR and cardiac defibrillation has led to a rapid increase in successful resuscitations. Patients who reach the hospital after cardiac arrest may develop various neurological deficits or clinical syndromes that may preclude recovery to their premorbid baseline. Consequently, clinicians are faced with not only predicting outcome regarding wakefulness and independence but also with long term therapeutic management. Several neurological syndromes have been reported as consequences of HI-BI. This review will describe some of the more common syndromes seen after HI-BI, including the various levels of arousal, seizures, myoclonus, movement disorders, cognitive impairments, and other specific neurological abnormalities.

Emerging treatments for motor rehabilitation after stroke.

Although numerous treatments are available to improve cerebral perfusion after acute stroke and prevent recurrent stroke, few rehabilitation treatments have been conclusively shown to improve neurologic recovery. The majority of stroke survivors with motor impairment do not recover to their functional baseline, and there remains a need for novel neurorehabilitation treatments to minimize long-term disability, maximize quality of life, and optimize psychosocial outcomes. In recent years, several novel therapies have emerged to restore motor function after stroke, and additional investigational treatments have also shown promise. Here, we familiarize the neurohospitalist with emerging treatments for poststroke motor rehabilitation. The rehabilitation treatments covered in this review will include selective serotonin reuptake inhibitor medications, constraint-induced movement therapy, noninvasive brain stimulation, mirror therapy, and motor imagery or mental practice.

Lethal giant cell arteritis with multiple ischemic strokes despite aggressive immunosuppressive therapy.

Two patients with giant cell arteritis (GCA) had a malignant course despite aggressive immunosuppressive therapy. A 63-year-old woman presented with symptoms of headache, jaw claudication, scalp paresthesia, and visual disturbances. A temporal artery biopsy showed GCA. While on prednisone, she suffered ischemic strokes, and serial cerebral angiograms demonstrated bilateral, severe and progressive narrowing of distal vertebral and internal carotid arteries. Despite escalating immunosuppressive therapies, she suffered more infarcts and eventually died. Postmortem examination of arteries showed no active inflammation. A 65-year-old man presented with extrapyramidal symptoms though no symptoms typical of GCA. Imaging showed multiple ischemic strokes. Because serial angiograms demonstrated findings similar to the first patient, he underwent temporal artery biopsy that showed GCA. He died 7 months after his presentation with complications of aggressive immunosuppressive therapy. These two patients confirm that GCA can follow a lethal course despite escalating immunosuppressive therapies. Our two patients were unique in that eventually both anterior and posterior circulations were involved bilaterally in a characteristic location where the arteries penetrate the dura. This pattern should always raise the possibility of GCA and, if confirmed, should prompt aggressive immunosuppressive therapy. The dismal outcomes despite this approach may suggest a non-inflammatory arteriopathy, as seen on necropsy in one of our patients. Such an arteriopathy may require novel therapies to be considered for this severe variant of GCA.

Effect of Continuous Positive Airway Pressure on Stroke Rehabilitation: A Pilot Randomized Sham-Controlled Trial

STUDY OBJECTIVES Obstructive sleep apnea (OSA) predicts poor functional outcome after stroke and increases the risk for recurrent stroke. Less is known about continuous positive airway pressure (CPAP) treatment on stroke recovery. METHODS In a pilot randomized, double-blind, sham-controlled trial, adult stroke rehabilitation patients were assigned to auto-titrating or sham CPAP without diagnostic testing for OSA. Change in Functional Independence Measure (FIM), a measure of disability, was assessed between rehabilitation admission and discharge. RESULTS Over 18 months, 40 patients were enrolled and 10 withdrew from the study: 7 from active and 3 from sham CPAP (p > 0.10). For the remaining 30 patients, median duration of CPAP use was 14 days. Average CPAP use was 3.7 h/night, with at least 4 h nightly use among 15 patients. Adherence was not influenced by treatment assignment or stroke severity. In intention-to-treat analyses (n = 40), the median change in FIM favored active CPAP over sham but did not reach statistical significance (34 versus 26, p = 0.25), except for the cognitive component (6 versus 2.5, p = 0.04). The on-treatment analyses (n = 30) yielded similar results (total FIM: 32 versus 26, p = 0.11; cognitive FIM: 6 versus 2, p = 0.06). CONCLUSIONS A sham-controlled CPAP trial among stroke rehabilitation patients was feasible in terms of recruitment, treatment without diagnostic testing and adequate blinding-though was limited by study retention and CPAP adherence. Despite these limitations, a trend towards a benefit of CPAP on recovery was evident. Tolerance and adherence must be improved before the full benefits of CPAP on recovery can be assessed in larger trials.

Airhead: intraparenchymal pneumocephalus after commercial air travel

BACKGROUND Commercial air travel either in the postoperative setting or after open skull fracture has the potential to place patients at unnecessary risk. Although the timing is not clearly known, it should be established that there is no persistent fistulous tract that could introduce additional intraparenchymal air. CASE DESCRIPTION We present a case of a gentleman with dramatic pneumocephalus after commercial air travel. CONCLUSION Because of the potential for serious and permanent injury that can result from a dramatic and sustained increase in intracranial pressure, air travel should be delayed until there is no evidence of a fistulous tract. We discuss some basic in-flight options and precautions should change in timing of travel not be possible.

Jaw Dystonia and Reversible Basal Ganglia Changes as an Initial Presentation of Systemic Lupus Erythematosus

Dystonia as a manifestation of neuropsychiatric lupus erythematosus (NPSLE) is uncommon. We report a 25-year-old woman who experienced progressive confusion, reduced speech, and difficulty opening her mouth approximately 2 weeks after development of a facial rash. Brain imaging showed bilateral, symmetric signal abnormalities within the basal ganglia and subcortical white matter. Despite treatment with high-dose steroids, she continued to have difficulty speaking with evidence of jaw dystonia on examination. Jaw dystonia rapidly improved with the initiation of levodopa. Repeat evaluation 3 months later exhibited the absence of jaw dystonia and near resolution of the imaging abnormalities. Our patient demonstrated a unique presentation with jaw dystonia refractory to traditional treatment for NPSLE. Such a presentation likely represents a severe variant of NPSLE requiring both immunosuppressive and symptomatic therapies.

A 61-Year-Old Woman With Headaches and Aphasia.

A 61-year-old woman with a history of migraine headaches and focal segmental glomerulosclerosis, chronically immunosuppressed with mycophenolate mofetil, presented to a hospital with 2 weeks of left-sided headache and word finding difficulty. She described her headaches as constant pain similar in location and character to her typical migraines and involving her left face. The day prior to presentation, she developed slowed speech, stuttering, and confusion. On admission, a noncontrast computed tomography scan of her head revealed a large hypodense lesion involving the left hemisphere with 7 mm of midline shift. Magnetic resonance imaging (MRI) of the brain showed a large, confluent area of increased T2 and decreased T1 signal involving the left frontal, parietal, and temporal lobes (Figure 1). Cerebrospinal fluid (CSF) analysis revealed 1 nucleated cell, elevated protein and normal cytology and flow cytometry (Table 1). Due to concern for vasogenic edema from an underlying mass lesion, treatment with intravenous dexamethasone 6 mg 4 times daily was initiated on hospital day 1. Subsequently, a diagnostic procedure was obtained. She was transferred to our facility on hospital day 7 for further evaluation. She reported significant improvement in her cognition and word finding difficulties after starting dexamethasone. She endorsed malaise over the past month though denied fevers, loss of consciousness, weakness, sensory changes, seizure, visual disturbance, hearing changes, nausea, or vomiting. On examination, she was alert and interactive. Her temperature was 36.0 C, blood pressure 141/78 mm Hg, and pulse 48 beats per minute. Her neurologic examination was notable for crisp discs on fundoscopic evaluation, expressive aphasia characterized by word-finding difficulty and paraphasic errors, impaired delayed recall, and mild gait ataxia. Laboratory studies revealed a white blood cell count of 14 400/mL (normal 4.3-10 thousand/mL). A repeat MRI 8 days after the initial brain MRI demonstrated interval decrease in midline shift to 3 mm and a persistent large area of confluent left hemisphere T2 hyperintensity. Susceptibility-weighted imaging (SWI) showed multiple microhemorrhages confined to the area of T2 hyperintensity that were not noted on the gradient echo (GRE) sequence of the prior MRI (Figure 1).

Early diagnosis and treatment of obstructive sleep apnea after stroke: Are we neglecting a modifiable stroke risk factor?Authors Respond:

Davis et al.1 highlight the importance of timely identification of sleep-disordered breathing in patients who have had an acute stroke. In the immediate aftermath of a stroke, patients are frequently obtunded and so it is not unusual for symptoms of sleep-disordered breathing such as snoring, gasping, and choking sensation while asleep and excessive daytime sleepiness to be erroneously attributed to the stroke itself. While obstructive sleep apnea is the most common, central and mixed sleep apnea should be kept in mind especially in patients who have a bulbar stroke. Another unresolved issue is the appropriate time after a stroke when sleep apnea should be diagnosed and treated; the grade of sleep-disordered breathing may spontaneously improve and continuous positive airway pressure (CPAP) requirements decrease as the stroke becomes subacute and finally chronic. Repeating the sleep study and, if warranted, retitrating the CPAP a few months after the stroke is prudent. N. Sethi serves as Associate Editor for The Eastern Journal of Medicine … Correspondence to: marialuisa.sacchetti{at}uniroma1.it Correspondence to: apd77{at}uw.edu

Diagnostic Dilemma of a Young Man With Fever and Headaches

A 23-year-old man was admitted to the hospital in the fall because of fever and headache. He had been well until 5 days earlier when he developed headaches associated with photophobia, neck pain, nausea, and vomiting. He had no significant medical history and took no medications. He lived with his parents in Seattle, Washington, and took classes at a local college. He had immigrated from China in 2007.