White Blood Cell Count Improves Prediction of Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Immune dysregulation has long been implicated in the development of delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVE

To determine the relationship of inflammatory cell biomarkers with DCI.

METHODS

We evaluated 849 aSAH patients who were enrolled into a prospective observational cohort study and had a white blood cell (WBC) differential obtained within 72 h of bleed onset.

RESULTS

WBC count > 12.1 × 109/L (odds ratio 4.6; 95% confidence interval [CI]: 1.9-11, P < 0.001) was the strongest Complete Blood Count (CBC) predictor of DCI after controlling for clinical grade (P < .001), thickness of SAH blood on admission computed tomography (P = .002), and clipping aneurysm repair (P < .001). A significant interaction between clinical grade and WBC count (odds ratio 0.8, 95% CI: 0.6-1.0, P = .02) revealed that good-grade patients with elevated WBC counts (49%: 273/558) had increased odds for DCI indistinguishable from poor-grade patients. Multivariable Cox regression also showed that elevated WBC counts in good-grade patients increased the hazard for DCI to that of poor-grade patients (hazard ratio 2.1, 95% CI 1.3-3.2, P < .001). Receiver operating characteristic curve analysis of good-grade patients revealed that WBC count (area under the curve [AUC]: 0.63) is a stronger DCI predictor than the modified Fisher score (AUC: 0.57) and significantly improves multivariable DCI prediction models (Z = 2.0, P = .02, AUC: 0.73; PPV: 34%; NPV: 92%).

CONCLUSION

Good-grade patients with early elevations in WBC count have a similar risk and hazard for DCI as poor-grade patients. Good-grade patients without elevated WBC may be candidates to be safely downgraded from the intensive care unit, leading to cost savings for both patient families and hospitals.

Abstract TP117: Outcomes of Elective Carotid Stenting in the Octogenarians

Background: The CREST trial showed that risk of stroke, MI, death, and composite of the any of the 3 adverse events during the periprocedural period of carotid artery stent (CAS) is 4.1%, 1.1%. 0.7%, and 7.2% respectively. We aim to assess trends of periprocedural outcomes after CAS based on different age strata.

Methods: A cohort of patients with CAS is identified from the National In patient Sample database using the procedure codes (00.63) for the years 2001 through 2009. We only included elective admissions for CAS. Missing observations on the death status are eliminated. Age was stratified as follows: < 60, 61-70, 71-80, and > 80. Trend analysis for the following periprocedural outcomes: peri-procedure stroke, myocardial infarction ‘MI’, and death; was performed across different age strata. The Cochrane-Armitage test was used for trend analysis.

Results: Over 9 years, 10,655 CAS procedures were performed; 1818 (17.1%) were performed in the octogenarians. Race and gender distribution was similar across the age strata; men and Whites were predominant. In addition to age, co-morbid high risk factors were documented in 91% of the octogenarians compared to 83.2% of those < 60. The overall periprocedural outcome of stroke, MI and death across all ages is 2.37%, (stroke 1.6%, MI 0.66% and death 0.37%). Unfavorable periprocedural outcomes in different age strata are as follows: < 60 (1.1%), 61-70 (1.9%), 71-80 (3%), and > 80 (2.75%); trend P value < 0.0001. The risk of stroke is as follows: < 60 (0.72%), 61-70 (1.3%), 71-80 (2.0%), and > 80 (1.9%), P value < 0.0003; and MI < 60 (0.33%), 61-70 (0.52%), 71-80 (0.85%), and > 80 (0.77%), P value < 0.03. Mortality remained between 0.27 and 0.44 in different age strata; P = 0.54.

Conclusion: In this study, periprocedural risks of stroke and MI are lower than what was reported in the CREST trial. A slight increase in these risks is noted with age, though appeared to plateau after age of 70 years.

Traumatic carotid-rosenthal fistula treated with Jostent Graftmaster

Traumatic injuries of the carotid artery may result in severe morbidity and mortality. The most common location of carotid artery injury is the cavernous segment, which may result in fistulous connection to the cavernous sinus and ophthalmic veins, which in turn lead to pressure symptoms in the ipsilateral orbit. Unlike the commonly reported direct traumatic carotid-cavernous fistula, we describe an unusual case of a 38-year-old man presented with a traumatic brain injury led to a fistula connection between the cavernous carotid artery and the ipsilateral basal vein of Rosenthal, with eventual drainage to the straight and transverse sinuses. The basal vein of Rosenthal is usually formed from confluence of anterior and middle cerebral veins deep in the Sylvian fissure and drain the insular cortex and the cerebral peduncles to the vein of Galen. Immediate endovascular deployment of a covered stent in the cavernous carotid artery allowed sealing the laceration site. Three months follow up showed a non-focal neurological examination and healed carotid laceration over the covered stent.

Treatment of cerebral aneurysms in children: analysis of the Kids' Inpatient Database

OBJECT.: Endovascular coiling and surgical clipping are viable treatment options of cerebral aneurysms. Outcome data of these treatments in children are limited. The objective of this study was to determine hospital mortality and complication rates associated with surgical clipping and coil embolization of cerebral aneurysms in children, and to evaluate the trend of hospitals' use of these treatments.

METHODS

The authors identified a cohort of children admitted with the diagnoses of cerebral aneurysms and aneurysmal subarachnoid hemorrhage from the Kids' Inpatient Database for the years 1998 through 2009. Hospital-associated complications and in-hospital mortality were compared between the treatment groups and stratified by aneurysmal rupture status. A multivariate regression analysis was used to identify independent variables associated with in-hospital mortality. The Cochrane-Armitage test was used to assess the trend of hospital use of these operations.

RESULTS

A total of 1120 children were included in this analysis; 200 (18%) underwent aneurysmal clipping and 920 (82%) underwent endovascular coiling. Overall in-hospital mortality was higher in the surgical clipping group compared with the coil embolization group (6.09% vs 1.65%, respectively; adjusted odds ratio [OR] 2.52, 95% CI 0.97-6.53, p = 0.05). The risk of postoperative stroke or hemorrhage was similar between the two treatment groups (p = 0.86). Pulmonary complications and systemic infection were higher in the surgical clipping population (p < 0.05). The rate of US hospitals' use of endovascular coiling has significantly increased over the years included in this study (p < 0.0001). Teaching hospitals were associated with a lower risk of death (OR 0.13, 95% CI 0.03-0.46; p = 0.001).

CONCLUSIONS

Although both treatments are valid, endovascular coiling was associated with fewer deaths and shorter hospital stays than clip placement. The trend of hospitals' use of coiling operations has increased in recent years.

Abstract WP239: Stroke Mimics Treated with Thrombolysis: A Single Center Experience

Background: Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. Alternative hypothesis is a higher rate of stroke mimics (SM) among AIS treated in a non-specialized stroke centers and then transferred to comprehensive centers.

Methods: Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over one academic year. Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge information were collected. We also identified those who were treated in outside facility and then transferred to the tertiary center (i.e. drip-and-ship paradigm). Comparative and adjusted analysis to identify predictors for stroke mimics was performed.

Results: 120 patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = 0.0003), had a slight female preponderance (55% versus 46%; P = 0.46); and more likely to harbor a psychiatric diagnosis (45% versus 9%; P = <0.0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared to 65% of those with AIS (P= 0.02). None of SM had any hemorrhagic complications and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (OR 12.8, 95% CI 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4).

Conclusion: Drip-and-ship paradigm and the presence of any psychiatric history predict the diagnosis of SM. None of the SM had any thrombolysis related complication and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment of AIS

A role for human endogenous retrovirus-K (HML-2) in rheumatoid arthritis: investigating mechanisms of pathogenesis

Human endogenous retroviruses (HERVs) are remnants of ancient retroviral infections within the human genome. These molecular fossils draw parallels with present-day exogenous retroviruses and have been linked previously with immunopathology within rheumatoid arthritis (RA). Mechanisms of pathogenesis for HERV-K in RA such as molecular mimicry were investigated. To clarify a role for HERVs in RA, potential autoantigens implicated in autoimmunity were scanned for sequence identity with retroviral epitopes. Short retroviral peptides modelling shared epitopes were synthesized, to survey anti-serum of RA patients and disease controls. A novel real-time polymerase chain reaction (PCR) assay was also developed to quantify accurately levels of HERV-K (HML-2) gag expression, relative to normalized housekeeping gene expression. Both serological and molecular assays showed significant increases in HERV-K (HML-2) gag activity in RA patients, compared to disease controls. The real-time PCR assay identified significant up-regulation in HERV-K mRNA levels in RA patients compared to inflammatory and healthy controls. Exogenous viral protein expression and proinflammatory cytokines were also shown to exert modulatory effects over HERV-K (HML-2) transcription. From our data, it can be concluded that RA patients exhibited significantly elevated levels of HERV-K (HML-2) gag activity compared to controls. Additional factors influencing HERV activity within the synovium were also identified. The significant variation in RA patients, both serologically and transcriptionally, may be an indication that RA is an umbrella term for a number of separate disease entities, of which particular HERV polymorphisms may play a role in development.

[Hydatid cyst of the heart simulating coronary ischemia]

Cardiac echinococcosis is rare despite endemic occurrence of echinococcosis in some regions of the world. Clinical presentation can vary and may be misleading. Diagnosis is facilitated by new imaging techniques. Surgery is mandatory to avoid serious complications. We report a case of cardiac echinococcosis with pseudo, ischemic clinical and electrical presentation.

[Renovascular arterial hypertension in the framework of von Recklinghausen's neurofibromatosis. Apropos of a case]

Arterial hypertension in patients with neurofibromatosis is most often due to an associated pheochromocytoma. In rare cases the etiology of arterial hypertension is renovascular. Surgical treatment is mandatory when the stenosis is located in the proximal segment of the vessel. Angioplasty is hazardous in this setting due to the fibrotic nature of the culprit lesion. The authors report a case of ostial narrowing of the right renal artery in a 16-year-old girl with severe arterial hypertension and neurofibromatosis. The operation consisted of resection of the culprit lesion and reimplantation of the renal artery on the aorta. Postoperatively her blood pressure returned to normal.