W. Scott Burgin

High Rate of Complete Recanalization and Dramatic Clinical Recovery During tPA Infusion When Continuously Monitored With 2-MHz Transcranial Doppler Monitoring

Background and Purpose—Clot dissolution with tissue plasminogen activator (tPA) can lead to early clinical recovery after stroke. Transcranial Doppler (TCD) with low MHz frequency can determine arterial occlusion and monitor recanalization and may potentiate thrombolysis. Methods—Stroke patients receiving intravenous tPA were monitored during infusion with portable TCD (Multigon 500M; DWL MultiDop-T) and headframe (Marc series; Spencer Technologies). Residual flow signals were obtained from the clot location identified by TCD. National Institutes of Health Stroke Scale (NIHSS) scores were obtained before and after tPA infusion. Results—Forty patients were studied (mean age 70±16 years, baseline NIHSS score 18.6±6.2, tPA bolus at 132±54 minutes from symptom onset). TCD monitoring started at 125±52 minutes and continued for the duration of tPA infusion. The middle cerebral artery was occluded in 30 patients, the internal carotid artery was occluded in 11 patients, the basilar artery was occluded in 3 patien...

Ultrasound-enhanced thrombolysis for acute ischemic stroke: phase I. Findings of the CLOTBUST trial.

Background. Tissue plasminogen activator (TPA) activity may be enhanced with ultrasound, potentially 2 MHz transcranial Doppler (TCD). The authors present Phase I data of the CLOTBUST (Combined Lysis of Thrombus in Brain ischemia using transcranial Ultrasound and Systemic TPA). Subjects and Methods. Nonrandomized stroke patients with proximal arterial occlusion on a prebolus TCD receiving intravenous 0.9 mg/kg TPA within 3 hours after stroke onset were monitored with portable diagnostic TCD equipment and a standard headframe. Complete recanalization was defined as thrombolysis in brain ischemia (TIBI) flow grades 4–5. Results. 55 patients (mean age 69 ± 15 years, median baseline NIH Stroke Scale [NIHSS] 18, range 4–29, 90% with 39 points) were treated at 125 ± 36 minutes from symptom onset. TCD monitoring began at 117 ± 39 minutes. Complete recanalization on TCD within 2 hours after bolus was found in 20 patients (36%). Dramatic recovery (NIHSS score = 3) occurred in 20% at 2 hours and in 24% at 24ours. Overall improvement by = 4 NIHSS points was found in9% at 24 hours. Improvement was associated with recanalization during or shortly after TPA infusion (•r 2= .5, P=03); however, in 6/20 patients with complete recanalization (30%), no immediate clinical change was noticed within 2 hours. Overall symptomatic hemorrhage rate was 5.5%. Conclusions. Continuous TCD insonation for up to 2 hours at maximum intensities allowed by current bio‐safety guidelines is safe. Dramatic recovery and complete recanalization shortly after TPA bolus are feasible goals for thrombolysis given with TCD monitoring.

Ischemic stroke after use of the synthetic marijuana “spice”

Objectives: To report and associate acute cerebral infarctions in 2 young, previously healthy siblings with use of the street drug known as “spice” (a synthetic marijuana product, also known as “K2”), which they independently smoked before experiencing acute embolic-appearing ischemic strokes. Methods: We present history, physical examination, laboratory data, cerebrovascular imaging, echocardiogram, ECG, and hospital course of these patients. Results: We found that in both siblings spice was obtained from the same source. The drug was found to contain the schedule I synthetic cannabinoid JWH-018. Full stroke workup was unrevealing of a stroke etiology; urine drug screen was positive for marijuana. Conclusions: We found that our 2 patients who smoked the street drug spice had a temporal association with symptoms of acute cerebral infarction. This association may be confounded by contaminants in the product consumed (i.e., marijuana or an unidentified toxin) or by an unknown genetic mechanism. The imaging of both patients suggests an embolic etiology, which is consistent with reports of serious adverse cardiac events with spice use, including tachyarrhythmias and myocardial infarctions.

A Cost-Effectiveness Analysis of Carotid Artery Stenting Compared With Endarterectomy

Endarterectomy and angioplasty with stenting have emerged as 2 alternative treatments for carotid artery stenosis. This studys objective was to determine the cost-effectiveness of carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) in symptomatic subjects who are suitable for either intervention. A Markov analysis of these 2 revascularization procedures was conducted using direct Medicare costs (2007 US

Hemorrhagic stroke following use of the synthetic marijuana “spice”

) and characteristics of a symptomatic 70-year-old cohort over a lifetime. In the base case analysis, CAS produced 8.97 quality-adjusted life-years, compared with 9.64 quality-adjusted life-years for CEA. The incremental cost of stenting was

Effects of age on outcome in the SENTIS trial : better outcomes in elderly patients

17,700, and thus CAS was dominated by CEA. Sensitivity analyses show that the long-term probabilities of major stroke or mortality influenced the results. In the base case analysis, CEA for patients with symptomatic stenosis has a greater benefit than CAS, with lower direct costs. With 59% probability, CEA will be the optimal intervention when all of the model assumptions are varied simultaneously.

Deterioration following improvement with tPA therapy: carotid thrombosis and reocclusion.

The association between the street drug spice (K-2 or herbal incense), a synthetic marijuana, and intracranial hemorrhage (ICH) has not yet been described, but it has with acute ischemic stroke (AIS),1 seizure, and myocardial infarction.2 Two young patients (31 and 25 years old) independently presented to our hospital with subarachnoid hemorrhage (SAH) after spice inhalation. The first also had 2 large intraparenchymal hemorrhages (IPH); the other also had AIS. Both were previously healthy without hypertension, coagulopathy, bleeding diathesis, thrombocytopenia, intracranial aneurysm, arteriovenous malformation, connective tissue disease, or anticoagulant/antiplatelet medication use.

Sex Disparities in Ischemic Stroke Care: FL-PR CReSD Study (Florida–Puerto Rico Collaboration to Reduce Stroke Disparities)

Background: Increasing age is associated with poor outcome after stroke. The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke (SENTIS) trial explored the augmentation of collateral circulation to the ischemic penumbra as a novel approach to stroke treatment. The aim of this post hoc analysis was to examine the effect of age on outcomes in the SENTIS trial. Methods: Using data from the randomized controlled SENTIS trial, we explored outcomes of cerebral blood flow augmentation using the NeuroFlo™ device in patients categorized by age strata at 70 and 80 years. We evaluated outcomes of overall serious adverse event (SAE) and intracerebral hemorrhage (ICH) rates, freedom from all-cause and stroke-related mortality, and independent functional outcome as defined by the modified Rankin Scale score (mRS ≤2). Results: The SENTIS as-treated cohort included 251 patients ≥70 years and 107 patients ≥80 years. Elderly SENTIS patients included a higher percentage of women and Caucasians than the younger group. Patients in the older group more frequently had vascular risk factors including hypertension, previous stroke, transient ischemic attacks and atrial fibrillation. However, baseline risk-factor profile, stroke severity, and time to randomization did not differ between the treated and nontreated elderly patients. The older patients treated with NeuroFlo had significantly higher chances for survival and for obtaining an independent functional state (mRS ≤2) compared with those who were not treated. Rates of SAEs and ICHs did not differ between the treatment groups. Conclusions: NeuroFlo treatment is safe and results in better outcomes for elderly patients. This may be the result of recruitment and support of already existing collateral systems in these patients.

Racial-Ethnic Disparities in Acute Stroke Care in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study.

Clinical improvement of ≥4 points on the NIH Stroke Scale (NIHSS) was seen in 47% of patients 24 hours after treatment with IV tissue plasminogen activator (tPA) for acute ischemic stroke.1 Arterial recanalization can be associated with early recovery;2 following improvement, however, 15% of patients experience clinical deterioration.3 Transcranial Doppler (TCD) ultrasonography has been used to detect arterial occlusion and monitor recanalization during thrombolysis.4 The authors report the clinical and TCD findings in a patient who improved, then subsequently deteriorated, while receiving tPA therapy. A 42-year-old, right-handed woman was seen 80 minutes after the acute onset of right hemiplegia, global aphasia, eye deviation to the left, and a right homonymous hemianopsia (NIHSS score 24). Her medial history included smoking, non–insulin-dependent diabetes mellitus, and peripheral vascular disease requiring bilateral femoral–popliteal bypasses. She had no history of cardiac or cerebral ischemia, and was not taking any antiplatelet treatment. A head CT scan showed a hyperdense left middle cerebral artery (MCA) and no hemorrhage. At 90 minutes from symptom onset, a TCD was performed according to a published protocol,4 using a single-channel, 2-MHz portable unit (Multigon 500M, Yonkers, NY), and head-frame fixation (Marc 500, Spencer Technologies, Seattle, WA). The TCD was consistent with a proximal M1 MCA and A1 anterior cerebral artery (ACA) occlusion ( figure, frame 1) followed by rapid progression to a terminal internal carotid artery (ICA) occlusion (see the figure, frame 2). Within 5 minutes, the …

Ischemic stroke after use of the synthetic marijuana “spice”Author Response

Background and Purpose— Sex-specific disparities in stroke care including thrombolytic therapy and early hospital admission are reported. In a large registry of Florida and Puerto Rico hospitals participating in the Get With The Guidelines—Stroke program, we sought to determine sex-specific differences in ischemic stroke performance metrics and overall thrombolytic treatment. Methods— Around 51 317 (49% women) patients were included from 73 sites from 2010 to 2014. Multivariable logistic regression with generalized estimating equations evaluated sex-specific differences in the prespecified Get With The Guidelines—Stroke metrics for defect-free care in ischemic stroke, adjusting for age, race-ethnicity, insurance status, hospital characteristics, individual risk factors, and the presenting stroke severity. Results— As compared with men, women were older (73±15 versus 69±14 years; P<0.0001), more hypertensive (67% versus 63%, P<0.0001), and had more atrial fibrillation (19% versus 16%; P<0.0001). Defect-free care was slightly lower in women than in men (odds ratio, 0.96; 95% confidence interval, 0.93–1.00). Temporal trends in defect-free care improved substantially and similarly for men and women, with a 29% absolute improvement in women (P<0.0001) and 28% in men (P<0.0001), with P value of 0.13 for time-by-sex interaction. Women were less likely to receive thrombolysis (odds ratio, 0.92; 95% confidence interval, 0.86–0.99; P=0.02) and less likely to have a door-to-needle time <1 hour (odds ratio, 0.83; 95% confidence interval, 0.71–0.97; P=0.02) as compared with men. Conclusions— Women received comparable stroke care to men in this registry as measured by prespecified Get With The Guidelines metrics. However, women less likely received thrombolysis and had door-to-needle time <1 hour, an observation that calls for the implementation of interventions to reduce sex disparity in these measures.