Shawna Cutting

Continuous aspiration prior to intracranial vascular embolectomy (CAPTIVE): a technique which improves outcomes

Background Modern stent retriever-based embolectomy for patients with emergent large vessel occlusion improves outcomes. Techniques aimed at achieving higher rates of complete recanalization would benefit patients. Objective To evaluate the clinical impact of an embolectomy technique focused on continuous aspiration prior to intracranial vascular embolectomy (CAPTIVE). Methods A retrospective review was performed of 95 consecutive patients with intracranial internal carotid artery or M1 segment middle cerebral artery occlusion treated with stent retriever-based thrombectomy over an 11-month period. Patients were divided into a conventional local aspiration group (traditional group) and those treated with a novel continuous aspiration technique (CAPTIVE group). We compared both early neurologic recovery (based on changes in National Institute of Health Stroke Scale (NIHSS) score), independence at 90 days (modified Rankin score 0–2), and angiographic results using the modified Thrombolysis in Cerebral Ischemia (TICI) scale including the TICI 2c category. Results There were 56 patients in the traditional group and 39 in the CAPTIVE group. Median age and admission NIHSS scores were 78 years and 19 in the traditional group and 77 years and 19 in the CAPTIVE group. Median times from groin puncture to recanalization in the traditional and CAPTIVE groups were 31 min and 14 min, respectively (p<0.0001). While rates of TICI 2b/2c/3 recanalization were similar (81% traditional vs 100% CAPTIVE), CAPTIVE offered higher rates of TICI 2c/3 recanalization (79.5% vs 40%, p<0.001). Median discharge NIHSS score was 10 in the traditional group and 3 in the CAPTIVE group; this difference was significant. There was also an increased independence at 90 days (25% traditional vs 49% CAPTIVE). Conclusions The CAPTIVE embolectomy technique may result in higher recanalization rates and better clinical outcomes.

Association of a Primary Stroke Center Protocol for Suspected Stroke by Large-Vessel Occlusion With Efficiency of Care and Patient Outcomes.

Importance While prehospital triage to the closest comprehensive stroke center (CSC) may improve the delivery of care for patients with suspected emergent large-vessel occlusion (ELVO), efficient systems of care must also exist for patients with ELVO who first present to a primary stroke center (PSC). Objective To describe the association of a PSC protocol focused on 3 key steps (early CSC notification based on clinical severity, vessel imaging at the PSC, and cloud-based image sharing) with the efficiency of care and the outcomes of patients with suspected ELVO who first present to a PSC. Design, Setting, and Participants In this retrospective cohort study, 14 regional PSCs unfamiliar with the management of patients with ELVO were instructed on the use of the following protocol for patients presenting with a Los Angeles Motor Scale score 4 or higher: (1) notify the CSC on arrival, (2) perform computed tomographic angiography concurrently with noncontract computed tomography of the brain and within 30 minutes of arrival, and (3) share imaging data with the CSC using a cloud-based platform. A total of 101 patients were transferred from regional PSCs to the CSC between July 1, 2015, and May 31, 2016, and received mechanical thrombectomy for acute ischemic stroke. The CSC serves approximately 1.7 million people and partners with 14 PSCs located between 6.4 and 73.6 km away. All consecutive patients with internal carotid artery or middle cerebral artery occlusions transferred over an 11-month period were reviewed, and they were divided into 2 groups based on whether the PSC protocol was partially or fully executed. Main Outcomes and Measures The primary outcomes were efficiency measures including time from PSC door in to PSC door out, time from PSC door to CSC groin puncture, and 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome). Results Although 101 patients were transferred, only 70 patients met the inclusion criteria during the study period. The protocol was partially executed for 48 patients (68.6%) (mean age, 77 years [interquartile range, 65-84 years]; 22 of the 48 patients [45.0%] were women) and fully executed for 22 patients (31.4%) (mean age, 76 years [interquartile range, 59-86 years]; 13 of the 22 patients [59.1%] were women). When fully executed, the protocol was associated with a reduction in the median time for PSC arrival to CSC groin puncture (from 151 minutes [95% CI, 141-166 minutes] to 111 minutes [95% CI, 88-130 minutes]; P < .001). This was primarily related to an improvement in the time from PSC door in to door out that reduced from a median time of 104 minutes (95% CI, 82-112 minutes) to a median time of 64 minutes (95% CI, 51-71.0 minutes) (P < .001). When the protocol was fully executed, patients were twice as likely to have a favorable outcome (50% vs 25%, P < .04). Conclusions and Relevance When fully implemented, a standardized protocol at PSCs for patients with suspected ELVO consisting of early CSC notification, computed tomographic angiography on arrival to the PSC, and cloud-based image sharing is associated with a reduction in time to groin puncture and improved outcomes.

Elevated International Normalized Ratio as a Manifestation of Post-thrombolytic Coagulopathy in Acute Ischemic Stroke

BACKGROUND A serious complication of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke is hemorrhage. Coagulation factors that may potentially increase the risk of bleeding after tPA are not well understood. METHODS We retrospectively reviewed 284 acute ischemic stroke patients who received tPA. Post-tPA coagulopathy was defined as a documented elevation of international normalized ration (INR) > 1.5 within 24 hours after IV tPA without a known cause. RESULTS We identified 21 (7.4%) patients with an elevated INR post-thrombolysis. The mean age was 68.3 years (standard deviation ± 11.9) and 57% were male. The mean initial National Institutes of Health Stroke Scale (pre-tPA) was 15.8 (range, 4-35). Liver disease or alcohol abuse was noted in 19%. There were 2 tPA protocol violations who received more than 90 mg tPA. The mean post-tPA INR was 2.03 (range, 1.5-4.7) and the elevation in INR was documented within a mean 5.4 hours (range, 1-15) after tPA initiation. Repeat INR levels returned to normal during their hospital stay in 19 patients. Hypofibrinogenemia was noted in 10 of 12 patients who had fibrinogen levels drawn within 48 hours after tPA initiation and in all 7 patients with fibrinogen levels drawn the same time as the elevated INR. Among the 6 patients with bleeding complications, 2 patients had symptomatic intracerebral hemorrhage. CONCLUSIONS We report an under-recognized early transient coagulopathy associated with elevated INR in stroke patients after treatment with tPA.

Three-Month Outcomes Are Poor in Stroke Patients with Cancer Despite Acute Stroke Treatment

INTRODUCTION Stroke risk is increased in cancer patients. Prognosis in these patients is poor, with higher in-hospital mortality and increased subsequent mortality. However, data on stroke in cancer patients are limited, specifically regarding acute stroke treatment and functional outcomes. We aim to determine the functional outcomes of cancer patients admitted with acute stroke. MATERIALS AND METHODS We retrospectively reviewed patients carrying a diagnosis of cancer who were admitted with acute ischemic stroke between March 2013 and February 2016. Demographics, cerebrovascular risk factors, stroke characteristics including acute treatment, and characteristics of their cancer history and treatment were abstracted. The primary outcome measures included in-hospital mortality and 3-month functional outcome (as assessed by the modified Rankin Scale [mRS] score, with mRS scores of 3-6 considered poor functional outcome). Further outcome measures included length of stay and discharge destination. FINDINGS Forty-nine patients met the inclusion criteria, with a median admission National Institutes of Health Stroke Scale score of 8. Twelve patients (24.4%) underwent acute stroke treatment. The most common stroke etiology was hypercoagulability of malignancy (21, 42.9%). The three-month mortality was 46.9%; half of survivors had poor functional outcome. Functional outcomes did not differ by cancer type, stage, or year since diagnosis; on multivariate analysis only high admission NIHSS score was associated with poor functional outcome (P = .002). CONCLUSION Nearly half of patients with cancer and stroke die within 3 months, and functional outcome is poor for 50% of 3-month survivors despite consideration of acute stroke treatment. Future research should address the role of hypercoagulability in the outcome prediction of stroke patients with cancer.

Primary Intraventricular Hemorrhage: Clinical Characteristics and Outcomes.

BACKGROUND Primary intraventricular hemorrhage (IVH) in adults is a rare neurologic disorder. The typical course, etiology, complications, and outcomes have not been well established. MATERIALS AND METHODS Consecutive patient records with a diagnosis of intracerebral hemorrhage admitted between May 2009 and June 2014 at a tertiary care center were retrospectively reviewed. Subjects were included in the study cohort if all neurologists and the radiology report agreed that the subject had an isolated IVH. Patients with intraparenchymal hemorrhage, subarachnoid hemorrhage, malignancy with hemorrhagic components, and hemorrhagic transformation of ischemic stroke were excluded. The electronic medical record, imaging report, and imaging studies were reviewed. FINDINGS Of 1692 cases reviewed, 33 (1.9%) had primary IVH. The most common presenting symptoms included altered mental status (48.5%), headache, (39.4%), and nausea (24.2%). In 36.3%, hypertension was found to be a contributing factor; 27.2% were attributed solely to hypertension. Vascular abnormalities were the primary etiology in 21.3% of patients. When observing outcomes, 61.8% were discharged home or to rehab, whereas 20.5% died or were placed in hospice care. A higher Graeb score was associated with an increased likelihood of death or hospice (8 versus 5, P = .02) CONCLUSION: This study is one of few to describe the etiology, contributing factors, and outcomes of primary IVH. As in prior studies, hypertension was a contributing factor, and vascular lesions were less common than expected. More research is necessary to further define the course and characteristics of this rare type of intracerebral hemorrhage.

Therapies for Hemorrhagic Transformation in Acute Ischemic Stroke

Opinion statementHemorrhagic transformation occurs in about 10–15% of patients with acute ischemic stroke. The treatment of hemorrhagic conversion is complex and includes blood pressure management, reversing coagulopathy, and managing its complications including increased intracranial pressure. Future research should be directed on identifying indications to treat and use of appropriate homeostatic regimens to effectively reverse the different anticoagulants and thrombolytic agents in an attempt to improve outcomes of patients with hemorrhagic transformation.

Telestroke in an Urban Setting

BACKGROUND Telestroke is a viable alternative in rural areas where neurologists or stroke expertise is unavailable. Urban applications of telestroke have not been previously described. MATERIALS AND METHODS All patients evaluated using remote telestroke technology at four urban spoke hospitals between March 2011 and March 2013 were included in this analysis. Telestroke services were provided by vascular fellowship-trained neurologists at one academic stroke center. Patient characteristics, time to initiation of consult, and treatment decisions were prospectively recorded. Stroke triage protocols and thrombolysis rates prior to initiation of telestroke were also obtained. RESULTS Four hundred ninety-eight patients were evaluated during the study period; mean age was 64.5 years, and 60.4% were female. Median time from initial emergency room call to start of teleconsult was 5 (range, 1-51) minutes. Average length of teleconsult was 30 minutes. Technical difficulties occurred in 80 (16.0%) teleconsults, but only 1 was major. Daytime calls (8 a.m.-5 p.m. Monday-Friday) accounted for 38.2% of teleconsults. Two hundred eighty-one patients (56.4%) were determined by teleconsult to have an acute ischemic stroke or transient ischemic attack (TIA). In 72 patients (14.5% overall; 25.6% of all ischemic stroke/TIA patients), intravenous alteplase (tissue plasminogen activator) was recommended. Transfer to the hub hospital occurred in 75 patients (15.1%). CONCLUSIONS Telestroke is a rapid and effective way to assess patients with suspected acute stroke in an urban setting. Its use may increase access to stroke neurologists and improve thrombolysis rates where competing responsibilities may delay, prevent, and even dissuade on-site evaluation by neurologists.

A Simple Score That Predicts Paroxysmal Atrial Fibrillation on Outpatient Cardiac Monitoring after Embolic Stroke of Unknown Source

BACKGROUND Occult paroxysmal atrial fibrillation (AF) is detected in 16%-30% of patients with embolic stroke of unknown source (ESUS). The identification of AF predictors on outpatient cardiac monitoring can help guide clinicians decide on a duration or method of cardiac monitoring after ESUS. METHODS We included all patients with ESUS who underwent an inpatient diagnostic evaluation and outpatient cardiac monitoring between January 1, 2013, and December 31, 2016. Patients were divided into 2 groups based on detection of AF or atrial flutter during monitoring. We compared demographic data, clinical risk factors, and cardiac biomarkers between the 2 groups. Multivariable logistic regression was used to determine predictors of AF. RESULTS We identified 296 consecutive patients during the study period; 38 (12.8%) patients had AF detected on outpatient cardiac monitoring. In a multivariable regression analysis, advanced age (ages 65-74: odds ratio [OR] 2.36, 95% confidence interval [CI] .85-6.52; ages 75 or older: OR 4.08, 95% CI 1.58-10.52) and moderate-to-severe left atrial enlargement (OR 4.66, 95% CI 1.79-12.12) were predictors of AF on outpatient monitoring. We developed the Brown ESUS-AF score: age (65-74 years: 1 point, 75 years or older: 2 points) and left atrial enlargement (moderate or severe: 2 points) with good prediction of AF (area under the curve .725) and was internally validated using bootstrapping. The percentage of patients with AF detected in each score category were as follows: 0: 4.2%; 1: 14.8%; 2: 20.8%; 3: 22.2%; 4: 55.6%. CONCLUSIONS The Brown ESUS-AF score predicts AF on prolonged outpatient monitoring after ESUS. More studies are needed to externally validate our findings.

Predictors of symptomatic intracranial haemorrhage in patients with an ischaemic stroke with neurological deterioration after intravenous thrombolysis

Objectives Early neurological deterioration prompting urgent brain imaging occurs in nearly 15% of patients with ischaemic stroke receiving intravenous tissue plasminogen activator (tPA). We aim to determine risk factors associated with symptomatic intracranial haemorrhage (sICH) in patients with ischaemic stroke undergoing emergent brain imaging for early neurological deterioration after receiving tPA. Methods We abstracted data from our prospective stroke database and included all patients receiving tPA for ischaemic stroke between 1 March 2015 and 1 March 2017. We then identified patients with neurological deterioration who underwent urgent brain imaging prior to their per-protocol surveillance imaging and divided patients into two groups: those with and without sICH. We compared baseline demographics, clinical variables, in-hospital treatments and functional outcomes at 90 days between the two groups. Results We identified 511 patients who received tPA, of whom 108 (21.1%) had an emergent brain CT. Of these patients, 17.5% (19/108) had sICH; 21.3% (23/108) of emergent scans occurred while tPA was infusing, though only 4.3% of these scans (1/23) revealed sICH. On multivariable analyses, the only predictor of sICH was a change in level of consciousness (OR 6.62, 95% CI 1.64 to 26.70, P=0.008). Conclusion Change in level of consciousness is associated with sICH among patients undergoing emergent brain imaging after receiving tPA. In this group of patients, preparation of tPA reversal agents while awaiting brain imaging may reduce reversal times. Future studies are needed to study the cost-effectiveness of this approach.

Stroke in a Young Patient: A Sentinel Presentation of Neurosyphilis and Human Immunodeficiency Virus (HIV)

Objective: To describe a case of ischemic stroke in a young patient leading to diagnosis of concomitant neurosyphilis and HIV infections. Background: Meningovascular syphilis is an early manifestation of neurosyphilis which can lead to an infectious endarteritis (Heubner’s arteritis) and subsequent ischemic stroke. In the present era, early neurosyphilis is most frequently seen in patients with concomitant HIV infection and previous series have demonstrated that neurosyphilis a common sentinel presentation of HIV. However, clinicians may fail to inquire about at-risk behaviors and test for these infections in young stroke patients. Methods: Case report of a young patient with multifocal ischemic stroke admitted to our institution. Results: A 19 year-old male with a history of migraine headaches, worsened over several months, presented to a community hospital after awakening with left sided hemiplegia, numbness, and slurred speech. MRI brain revealed multifocal ischemic stroke in the middle cerebral artery territory and right cerebellum. After an unrevealing initial workup, he was transferred to our academic facility for further investigation. Cerebral angiogram revealed focal areas of high-grade stenosis affecting multiple vessels, and delayed filling of the intracranial circulation suggestive of vasculitis. Serum RPR was reactive, and the cerebrospinal fluid (CSF) profile showed a neutrophilic pleocytosis, with reactive CSF VDRL. HIV testing sent on admission was positive. The patient disclosed a history of unprotected sexual relationships with multiple male partners. He did not have a personal history of sexually transmitted infections, nor was he aware of previous infected partners. Conclusions: Neurosyphilis should be a diagnostic consideration in young patients with ischemic stroke. Clinicians should also be aware of the high incidence of concomitant syphilis and HIV in at-risk populations. Effort should be made to inquire about high-risk behaviors and initiate testing for these infections early in the diagnostic workup to avoid missing these crucial diagnoses.