Sourabh Lahoti

Acid‐suppressive medication use in acute stroke and hospital‐acquired pneumonia

Pneumonia is a morbid complication of stroke, but evidence‐based strategies for its prevention are lacking. Acid‐suppressive medications have been associated with increased risk for nosocomial pneumonia in hospitalized patients. It is unclear whether these results can be extrapolated to stroke patients, where other factors strongly modulate pneumonia risk. We investigated the association between acid‐suppressive medication and hospital‐acquired pneumonia in patients with acute stroke.

Thrombolysis in Ischemic Stroke Without Arterial Occlusion at Presentation

Background and Purpose— None of the randomized trials of intravenous tissue-type plasminogen activator reported vascular imaging acquired before thrombolysis. Efficacy of tissue-type plasminogen activator in stroke without arterial occlusion on vascular imaging remains unknown and speculative. Methods— We performed a retrospective, multicenter study to collect data of patients who presented to participating centers during a 5-year period with ischemic stroke diagnosed by clinical examination and MRI and with imaging evidence of no vascular occlusion. These patients were divided into 2 groups: those who received thrombolytic therapy and those who did not. Primary outcome measure of the study was excellent clinical outcome defined as modified Rankin Scale of 0 to 1 at 90 days from stroke onset. Secondary outcome measures were good clinical outcome (modified Rankin Scale, 0–2) and perfect outcome (modified Rankin Scale, 0). Safety outcome measures were incidence of symptomatic intracerebral hemorrhage and poor outcome (modified Rankin Scale, 4–6). Results— A total of 256 patients met study criteria, 103 with thrombolysis and 153 without. Logistic regression analysis showed that patients who received thrombolysis had more frequent excellent outcomes with odds ratio of 3.79 (P<0.01). Symptomatic intracerebral hemorrhage was more frequent in thrombolysis group (4.9 versus 0.7%; P=0.04). Thrombolysis led to more frequent excellent outcome in nonlacunar group with odds ratio 4.90 (P<0.01) and more frequent perfect outcome in lacunar group with odds ratio 8.25 (P<0.01). Conclusions— This study provides crucial data that patients with ischemic stroke who do not have visible arterial occlusion at presentation may benefit from thrombolysis.

Thrombolysis in ischemic strokes with no arterial occlusion.

Rationale Twelve million people develop ischemic stroke each year world over and 30–40% of them do not have arterial occlusions at presentation. Trials conducted to study the efficacy of thrombolytic drug reported better outcome with use of thrombolytic drug but none studied the subtypes of ischemic strokes specifically and adequately. The subgroups of patients with no arterial occlusion at presentation continue to receive thrombolytic therapy without proven benefit and with some risk. Aim The aim of this article is to study whether intravenous thrombolysis with alteplase improves clinical outcome in ischemic stroke patients who do not have arterial occlusion at presentation. Design A retrospective medical record-based observational multicenter, multinational study. Outcomes Primary outcome measure would be clinical outcome at three-months from stroke onset measured by modified Rankin Scale and National Institute of Health Stroke Scale. Secondary outcome measure will be frequency of intracerebral hemorrhage causing worsening of clinical deficit defined as increase in National Institute of Health Stroke Scale by >4.

Therapeutic advances in understanding pathophysiology and treatment of cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis is an important cause of stroke in young population. A thorough understanding of its pathophysiology, clinical, and radiological features is needed for an early and timely diagnosis to initiate appropriate treatment before the disease becomes worse and difficult to manage. In this study, the recent advances in the therapeutics of cerebral venous thrombosis with brief overview of epidemiology, clinical features, and imaging modalities were reviewed. With emerging imaging modalities and therapeutic options, there has been a progress in ease of ability to diagnose and treat cerebral venous thrombosis, but because of the lack of a much-needed randomized controlled trial, there is deficiency of a standardized algorithm/protocol for treatment of cerebral sinus thrombosis, which remains mostly at the discretion of experiences of treating physicians. In this study, the presently available treatment and diagnostic modalities with pros and cons of each of them were reviewed.

ACDD(4) score: A simple tool for assessing risk of pneumonia after stroke.

BACKGROUND Pneumonia is a serious but a preventable stroke complication. Prediction scales for post-stroke pneumonia have been proposed with an intent to improve surveillance and prevention but they remain under-utilized in clinical practice. Most existing scales were developed using both ventilated and non-ventilated patients which may affect their accuracy. We derived and validated a novel, pragmatic scale to predict hospital-acquired pneumonia (HAP) after stroke employing only a non-ventilated stroke cohort. METHODS All consecutive patients admitted with acute stroke to a large hospital in Boston, Massachusetts, were identified using International Classification of Diseases, 9th revision (ICD-9) codes for acute ischemic strokes, intracerebral hemorrhages and confirmed by chart review. The following exclusion criteria were used: stroke occurring after hospitalization, pneumonia on admission, intubation, presence of brain or lung neoplasms, admission<48hours duration. HAP was defined using discharge ICD-9 codes. The association of relevant covariates with HAP was analyzed using multivariable stepwise logistic regression analysis to develop a scoring system and validated using bootstrapping. RESULTS A total of 1644 patients met study criteria; 144 (8.8%) developed HAP. An 8-point pneumonia prediction scale (ACDD4) was derived using significant covariates (age≥75=1; congestive heart failure=1; dysarthria=1; dysphagia=4). The risk of pneumonia varied between 2% and 33.9% with scores of 0 to 7, respectively. The c-statistic of the final model was 0.82 and bootstrap validation c-statistic was 0.81. CONCLUSION ACDD4 scale is a promising tool for predicting HAP in non-ventilated stroke patients that can be easily computed at the patients bedside. Subject term: cerebrovascular disease/stroke.

Stand alone mechanical thrombectomy (with penumbra system) for acute ischemic stroke based on MR imaging: Single center experience

BACKGROUND There is dismal rate of recanalization following intravenous thrombolysis of large vessel occlusive ischemic stroke. Trials on use of mechanical clot retrievers in acute ischemic stroke have used time from onset and clinical deficit at presentation as the main indications for intervention. MATERIALS AND METHODS Retrospective analysis of case records of acute stroke seen between May 2009 and October 2011 was done. It revealed 23 patients with acute ischemic stroke treated by mechanical thrombectomy using Penumbra system (PS). We used magnetic resonance (MR) imaging in correlation with clinical presentation to determine patients likely to benefit from recanalization and accordingly offered or at times deferred revascularization. A comparison of approach and outcomes was done with other relevant trials/reports. RESULTS Recanalization was achieved in all but one patient. Median modified Rankin Scale (mRS) score at 90 days was 2. Good clinical outcome (mRS ≤ 2) was achieved in 56.5% compared with 25% in Penumbra pivotal trial and 36% in multi Mechanical Embolus Removal in Cerebral Ischemia (multi MERCI) trial. All cause mortality was 13.04%. Symptomatic intracerebral hemorrhage (ICH) occurred in two patients (8.6%). CONCLUSION Analysis of our results suggests that PS is safe and effective (91.3%) in recanalizing cerebral vessels without concomitant thrombolytics.