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Magid-Bernstein J, Yan J, Herman AL, He Z, Johnson CW, Beatty H, Choi R, Velazquez S, Neeman E, Falcone G, Kim J, Petersen N, Gilmore EJ, Matouk C, Sheth K, Sansing L. Characterization of CSF inflammatory markers after hemorrhagic stroke and their relationship to disease severity. medRxiv 2023:2023.12.05.23299566. [PMID: 38106157 PMCID: PMC10723522 DOI: 10.1101/2023.12.05.23299566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Background The inflammatory response within the central nervous system is a key driver of secondary brain injury after hemorrhagic stroke, both in patients with intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (aSAH). In this study, we aimed to characterize inflammatory molecules in the blood and cerebrospinal fluid (CSF) of patients within 72 hours of hemorrhage to understand how such molecules vary across disease types and disease severity. Methods Biological samples were collected from patients admitted to a single-center Neurosciences Intensive Care Unit with a diagnosis of ICH or aSAH between 2014 and 2022. Control CSF samples were collected from patients undergoing CSF diversion for normal pressure hydrocephalus. A panel of immune molecules in the plasma and CSF samples was analyzed using Cytometric Bead Array assays. Clinical variables, including demographics, disease severity, and intensive care unit length of stay were collected. Results Plasma and/or CSF samples were collected from 260 patients (188 ICH patients, 54 aSAH patients, 18 controls). C-C motif chemokine ligand-2 (CCL2), interleukin-6 (IL-6), granulocyte-colony stimulating factor (G-CSF), interleukin-8 (IL-8), and vascular endothelial growth factor (VEGF), were detectable in the CSF within the first 3 days after hemorrhage, and all were elevated compared to plasma. Compared with controls, CCL2, IL-6, IL-8, G-CSF, and VEGF were elevated in the CSF of both ICH and aSAH patients (p<0.01 for all comparisons). VEGF was increased in ICH patients compared to aSAH patients (p<0.01). CCL2, G-CSF, and VEGF in the CSF were associated with more severe disease in aSAH patients only. Conclusions Within 3 days of hemorrhagic stroke, proinflammatory molecules can be detected in the CSF at higher concentrations than in the plasma. Early concentrations of some pro-inflammatory molecules may be associated with markers of disease severity.
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Gummerson CE, Parasram M, Peng TJ, Picard JM, Kahn PA, Angelus E, Bhatt S, de Havenon A, Jasne AS, Magid-Bernstein J. Acute and subacute neurovascular impact of cryptogenic air emboli. Surg Neurol Int 2023; 14:285. [PMID: 37680929 PMCID: PMC10481802 DOI: 10.25259/sni_382_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/25/2023] [Indexed: 09/09/2023] Open
Abstract
Background Cerebral air embolism is a rare cause of acute ischemic stroke that is becoming increasingly well-described in the literature. However, the mechanism and severity of this type of injury can vary, with ischemia typically emerging early in the course of care. To the best of our knowledge, delayed ischemia in this setting has not yet been described. Case Description A stroke code was called for an unresponsive, hospitalized, 75-year-old man. A computerized tomography (CT) scan of the head revealed air within the right greater than left hemispheric cortical veins with loss of sulcation, concerning for developing ischemia, and CT angiography revealed absent opacification of the distal cortical vessels in the right anterior cerebral artery and middle cerebral artery territories. Magnetic resonance imaging (MRI) of the brain was obtained 5.75 h after the patient's last known well-showed small areas of subtle cortical diffusion restriction. Follow-up CT head within 24 h showed near-complete resolution of the air emboli after treatment with 100% fraction of inspired oxygen on mechanical ventilation. Subsequent MRI, performed 4 days after the initial event, showed extensive cortical diffusion restriction and cerebral edema crossing vascular territories. Conclusion This case highlights that cerebral air emboli can cause delayed ischemia that may not be appreciated on initial imaging. As such, affected patients may require intensive neurocritical care management, close neurologic monitoring, and repeat imaging irrespective of initial radiographic findings.
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Affiliation(s)
| | - Melvin Parasram
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Teng J. Peng
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States
| | - John M. Picard
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Peter A. Kahn
- Pulmonary and Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States
| | - Evan Angelus
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States
| | - Shivani Bhatt
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States
| | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Adam S. Jasne
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States
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3
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Ammar AA, Elsamadicy AA, Ammar MA, Reeves BC, Koo AB, Falcone GJ, Hwang DY, Petersen N, Kim JA, Beekman R, Prust M, Magid-Bernstein J, Acosta JN, Herbert R, Sheth KN, Matouk CC, Gilmore EJ. Emergent external ventricular drain placement in patients with factor Xa inhibitor-associated intracerebral hemorrhage after reversal with andexanet alfa. Clin Neurol Neurosurg 2023; 226:107621. [PMID: 36791588 DOI: 10.1016/j.clineuro.2023.107621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Andexanet alfa (AA), a factor Xa-inhibitor (FXi) reversal agent, is given as a bolus followed by a 2-hour infusion. This long administration time can delay EVD placement in intracerebral hemorrhage (ICH) patients. We sought to evaluate the safety of EVD placement immediately post-AA bolus compared to post-AA infusion. METHODS We conducted a retrospective study that included adult patients admitted with FXi-associated ICH who received AA and underwent EVD placement The primary outcome was the occurrence of a new hemorrhage (tract, extra-axial, or intraventricular hemorrhage). Secondary outcomes included mortality, intensive care unit and hospital length of stay, and discharge modified Rankin Score. The primary safety outcome was documented thrombotic events. RESULTS Twelve patients with FXi related ICH were included (EVD placement post-AA bolus, N = 8; EVD placement post-AA infusion, N = 4). Each arm included one patient with bilateral EVD placed. There was no difference in the incidence of new hemorrhages, with one post-AA bolus patient had small, focal, nonoperative extra-axial hemorrhage. Morbidity and mortality were higher in post-AA infusion patients (mRS, post-AA bolus, 4 [4-6] vs. post-AA infusion 6 [5,6], p = 0.24 and post-AA bolus, 3 (37.5 %) vs. post-AA infusion, 3 (75 %), p = 0.54, respectively). One patient in the post-AA bolus group had thrombotic event. There was no difference in hospital LOS (post-AA bolus, 19 days [12-26] vs. post-AA infusion, 14 days [9-22], p = 0.55) and ICU LOS (post-AA bolus, 10 days [6-13] vs. post-AA infusion, 11 days [5-21], p = 0.86). CONCLUSION We report no differences in the incidence of tract hemorrhage, extra-axial hemorrhage, or intraventricular hemorrhage post-AA bolus versus post-AA infusion. Larger prospective studies to validate these results are warranted.
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Affiliation(s)
- Abdalla A Ammar
- Department of Pharmacy, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA; Department of Pharmacy, New York Presbyterian/Weill Cornell, 525 East 68th Street, New York, NY 10065, USA.
| | - Aladine A Elsamadicy
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Mahmoud A Ammar
- Department of Pharmacy, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA
| | - Benjamin C Reeves
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Andrew B Koo
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Guido J Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, Chapel Hill, NC 27599, USA
| | - Nils Petersen
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Jennifer A Kim
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Rachel Beekman
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Morgan Prust
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Jessica Magid-Bernstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Julián N Acosta
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Ryan Herbert
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Charles C Matouk
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
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Rivier C, Acosta J, Renedo D, Marini S, Magid-Bernstein J, Rosand J, Hanley DF, Ziai WC, Mayer S, Woo D, Sansing LH, Sheth KN, Anderson CD, Falcone GJ. Abstract TMP80: Sex Is Associated With Location, Severity And Outcome Of Intracerebral Hemorrhage: A Combined Analysis Of Four Landmark Studies. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tmp80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background and objective:
Small, single-center studies point to biological and clinical differences in women and men who sustain a spontaneous, non-traumatic intracerebral hemorrhage (ICH). Leveraging data from four landmark studies of ICH, we investigated the impact of sex on risk factors, location, severity and outcome of ICH.
Design:
Individual patient data meta-analysis of four studies of ICH, including three randomized clinical trials and one multi-ethnic observational study.
Setting:
Academic medical centers in the United States.
Patients:
Patients with neuroimaging confirmed ICH.
Measurements:
We conducted an individual patient data meta-analysis of four landmark studies of ICH: ERICH, ATACH-II, FAST and MISTIE-III. We evaluated whether sex was associated with specific risk factor profiles, hemorrhage location (deep or lobar), neuroimaging severity (hematoma volume and expansion), and poor 90-day functional outcomes (defined as a modified Rankin scale 4 to 6).
Main Results:
A total of 4,812 ICH patients were evaluated (mean age 62, 60% males). Men with ICH were younger, more likely to be smokers and diabetics, and less likely to be on anticoagulants (all p<0.05). In multivariable analyses, male sex was associated with non-lobar location (odds ratio [OR], 1.69; 95% CI, 1.42-2.01; p<0.001), larger hemorrhages (beta, 0.21; 95% CI, 0.14-0.28; p<0.001) and a higher risk of hematoma expansion (OR, 1.31; 95% CI, 1.10-1.56; p=0.003). Despite the larger hemorrhage volume and higher risk of expansion, male sex was associated with a 22% lower risk of poor outcomes (OR, 0.78; 95% CI, 0.67-0.91; p=0.001).
Conclusions:
Men with ICH are more likely to have vascular risk factors, have larger hemorrhage volumes, and have higher risk of hemorrhage expansion. They are also more likely to have a good outcome at 90 days compared to women.
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Affiliation(s)
| | | | | | | | | | | | | | - Wendy C Ziai
- JOHNS HOPKINS UNIV NEURO CRITICAL, Baltimore, MD
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Roh DJ, Asonye IS, Carvalho Poyraz F, Magid-Bernstein J, Joiner EF, Avadhani R, Awad I, Hanley D, Ziai WC, Murthy SB. Intraventricular Hemorrhage Expansion in the CLEAR III Trial: A Post Hoc Exploratory Analysis. Stroke 2022; 53:1847-1853. [PMID: 35086362 PMCID: PMC9133068 DOI: 10.1161/strokeaha.121.037438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The objective of this study was to evaluate factors associated with intraventricular hemorrhage (IVH) expansion and its association with long-term outcomes. METHODS We performed a post hoc analysis of the international, multi-center CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) which enrolled IVH patients between September 1, 2009, and January 31, 2015. The exposure was IVH expansion, defined as >1 mL increase in volume between baseline and stability computed tomography scans, before treatment randomization. We assessed factors associated with IVH expansion and secondarily assessed the relationship of IVH expansion with clinical outcomes: composite of death or major disability (modified Rankin Scale score, >3), and mortality alone at 6 months. The relationship of IVH expansion on ventriculoperitoneal shunt placement was additionally explored. Multivariable logistic regression was used for all analyses. RESULTS Of 500 IVH patients analyzed, the mean age was 59 (±11) years old, 44% were female and 135 (27%) had IVH expansion. In multivariable regression models, factors associated with IVH expansion were baseline parenchymal intracerebral hemorrhage (ICH) volume (adjusted odds ratio [OR], 1.04 per 1 mL increase [95% CI, 1.01-1.08]), presence of parenchymal hematoma expansion: >33% (adjusted OR, 6.63 [95% CI, 3.92-11.24]), time to stability head CT (adjusted OR, 0.71 per 1 hour increase [95% CI, 0.54-0.94]), and thalamic hematoma location (adjusted OR, 1.68 [95% CI, 1.01-2.79]) while additionally adjusting for age, sex, and race. In secondary analyses, IVH expansion was associated with higher odds of poor 6-month outcomes (adjusted OR, 1.84 [95% CI, 1.12-3.02]) but not mortality (OR, 1.40 [95% CI, 0.78-2.50]) after adjusting for baseline ICH volume, thalamic ICH location, age, anticoagulant use, Glasgow Coma Scale score, any withdrawal of care order, and treatment randomization arm. However, there were no relationships of IVH expansion on subsequent ventriculoperitoneal shunt placement (adjusted OR, 1.02 [95% CI, 0.58-1.80]) after adjusting for similar covariates. CONCLUSIONS In a clinical trial cohort of patients with large IVH, acute hematoma characteristics, specifically larger parenchymal volume, hematoma expansion, and thalamic ICH location were associated with IVH expansion. Given that IVH expansion resulted in poor functional outcomes, exploration of treatment approaches to optimize hemostasis and prevent IVH expansion, particularly in patients with thalamic ICH, require further study. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00784134.
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Affiliation(s)
- David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ifeyinwa S. Asonye
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Fernanda Carvalho Poyraz
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jessica Magid-Bernstein
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY
| | - Evan F. Joiner
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL
| | - Daniel Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wendy C. Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY
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Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.
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Affiliation(s)
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A. Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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7
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Magid-Bernstein J, Omran SS, Parikh NS, Merkler AE, Navi B, Kamel H. Reversible Cerebral Vasoconstriction Syndrome: Symptoms, Incidence, and Resource Utilization in a Population-Based US Cohort. Neurology 2021; 97:e248-e253. [PMID: 34050007 PMCID: PMC8302148 DOI: 10.1212/wnl.0000000000012223] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/14/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To estimate the incidence of hospitalization for reversible cerebral vasoconstriction syndrome (RCVS), we identified RCVS-related hospital admissions across 11 US states in 2016. METHODS We tested the validity of ICD-10 code I67.841 in 79 patients with hospital admissions for RCVS or other cerebrovascular diseases at 1 academic and 1 community hospital. After determining that this code had a sensitivity of 100% (95% confidence interval [CI], 82%-100%) and a specificity of 90% (95% CI, 79%-96%), we applied it to administrative data from the Healthcare Cost and Utilization Project on all hospital admissions across 11 states. Age- and sex-standardized RCVS incidence was calculated using census data. Descriptive statistics were used to analyze associated diagnoses. RESULTS Across 5,067,250 hospital admissions in our administrative data, we identified 222 patients with a discharge diagnosis of RCVS in 2016. The estimated annual age- and sex-standardized incidence of RCVS hospitalization was 2.7 (95% CI, 2.4-3.1) cases per million adults. Many patients had concomitant neurologic diagnoses, including subarachnoid hemorrhage (37%), ischemic stroke (16%), and intracerebral hemorrhage (10%). In the 90 days before the index admission, 97 patients had an emergency department (ED) visit and 34 patients a hospital admission, most commonly for neurologic, psychiatric, and pregnancy-related diagnoses. Following discharge from the RCVS hospital admission, 58 patients had an ED visit and 31 had a hospital admission, most commonly for neurologic diagnoses. CONCLUSIONS Using population-wide data, we estimated the age- and sex-standardized incidence of hospitalization for RCVS in US adults as approximately 3 per million per year.
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Affiliation(s)
- Jessica Magid-Bernstein
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Setareh S Omran
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Neal S Parikh
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Alexander E Merkler
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Babak Navi
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora
| | - Hooman Kamel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.M.-B., S.S.O., N.S.P., A.E.M., B.N., H.K.), Weill Cornell Medicine, New York, NY; and Department of Neurology (S.S.O.), University of Colorado School of Medicine, Aurora.
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8
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Magid-Bernstein J, Guo CY, Chow FC, Thakur KT. A rare case of HIV CNS escape in a patient previously considered a viral controller. Int J STD AIDS 2020; 31:694-698. [PMID: 32538333 DOI: 10.1177/0956462420922452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Human immunodeficiency virus (HIV) ribonucleic acid (RNA) levels generally remain undetectable in the cerebrospinal fluid of people living with HIV with peripheral viral suppression. Secondary HIV central nervous system (CNS) escape refers to the rare independent replication of HIV RNA in the central nervous system despite peripheral viral suppression that occurs in the setting of a concomitant non-HIV infection. We describe here a young man with perinatal HIV infection considered a viral controller who developed secondary HIV CNS escape in the setting of a presumed fungal CNS infection.
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Affiliation(s)
| | - Chu-Yueh Guo
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, CA, USA
| | - Felicia C Chow
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, CA, USA.,Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
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9
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Roh DJ, Carvalho Poyraz F, Magid-Bernstein J, Elkind MSV, Agarwal S, Park S, Claassen J, Connolly ES, Hod E, Murthy SB. Red Blood Cell Transfusions and Outcomes After Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:105317. [PMID: 32992186 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105317] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Low red blood cell (RBC) levels are associated with worse intracerebral hemorrhage (ICH) outcomes. However, relationships of RBC transfusions on ICH outcomes are unclear given the overlap of RBC transfusion, comorbidities, and disease severity. We investigated RBC transfusion relationships on ICH outcomes while accounting for comorbidities and disease severity. METHODS ICH hospitalizations between 2002 and 2011 and RBC transfusion exposure were identified from the Nationwide Inpatient Sample using ICD-9-CM codes. Logistic regression was used to study the relationship between RBC transfusion on outcomes after adjusting for demographics, baseline comorbidities, and markers of disease severity. Additional sensitivity analyses stratified by comorbidity burden and disease severity were performed. RESULTS Of 597,046 ICH hospitalizations, RBC transfusions were administered in 22,904 (4%). RBC transfusion was associated with higher odds of in-hospital mortality (adjusted OR: 1.22 [95%CI: 1.10-1.35]). In sensitivity analyses, RBC transfusions resulted in poor outcomes regardless of the comorbidity burden, but attenuation in this relationship was notable with lower comorbidities (adjusted OR 1.43 [95%CI: 1.34-1.51] vs 1.18 [95%CI: 1.10-1.29]). There were no associations of RBC transfusions with poor outcomes in hospitalizations without mechanical ventilation (adjusted OR 0.88 [95%CI: 0.83-1.13]) and in cases requiring ventriculostomy drains (adjusted OR 1.05 [95%CI: 0.97-1.10]). CONCLUSIONS In a large, nationally representative sample, RBC transfusion was associated with poor ICH outcomes. However, there were variations in this relationship based on comorbidities and disease severity. Additional prospective studies are required to assess direct risks and benefits from RBC transfusions in ICH.
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Affiliation(s)
- David J Roh
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Fernanda Carvalho Poyraz
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Jessica Magid-Bernstein
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Mitchell S V Elkind
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States; Mailman School of Public Health, Columbia University, New York, NY, United States.
| | - Sachin Agarwal
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Soojin Park
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Jan Claassen
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - E Sander Connolly
- Vagelos College of Physicians and Surgeons, Department of Neurosurgery, Columbia University, New York, NY, United States.
| | - Eldad Hod
- Vagelos College of Physicians and Surgeons, Department of Pathology and Cell Biology, Columbia University, New York, NY, United States.
| | - Santosh B Murthy
- Clinical and Translational Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY, United States.
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10
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Magid-Bernstein J, Salehi Omran S, Murthy SB, Merkler AE, Kamel H. Abstract WP228: Reversible Cerebral Vasoconstriction Syndrome: Presenting Symptoms, Incidence, and Outcomes in a Multi-State Cohort in the United States. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Reversible cerebral vasoconstriction syndrome (RCVS) is a syndrome of recurrent thunderclap headaches with transient cerebral vasoconstriction which can cause stroke. There are few population-based data on the incidence of RCVS as well as associated risk factors and complications.
Methods:
We performed a retrospective cohort study using administrative claims data from all nonfederal emergency department (ED) visits and hospitalizations in 11 U.S. states during 2016. Using
ICD-10
diagnosis code I67.841, we identified adult patients hospitalized with RCVS and evaluated associated diagnoses during prior, concurrent, and subsequent ED visits and hospitalizations. We used U.S. census data to estimate the age- and sex-standardized incidence of RCVS in the U.S. adult population. In a validation study, we reviewed the records of patients with a discharge diagnosis of RCVS and a random sample of patients with other cerebrovascular diagnoses at our medical center to estimate the sensitivity and specificity of the RCVS diagnosis code, and calculated the RCVS
2
score of patients with RCVS.
Results:
In our validation study, the sensitivity of the RCVS
ICD-10
code was 100% (95% CI, 66-100%) and the specificity 90% (95% CI, 74-98%); the median RCVS
2
score among patients diagnosed with RCVS was 6, supporting that the diagnosis code generally identified true cases of RCVS. In our statewide analysis, we identified 222 patients diagnosed with RCVS in 2016, equating to a U.S. incidence of 2.7 (95% CI, 2.4-3.1) per million adults per year. The mean age was 46.8 (±14.3) years, 63.5% of patients were white, and 77.5% were female. There were 17 ED visits (22% of all ED visits) for headache in the 3 months before RCVS diagnosis. During the RCVS hospitalization, the most common complications were subarachnoid hemorrhage (33.5%), followed by ischemic stroke (14.9%), intracerebral hemorrhage (9.3%), and seizures (9.3%). Most patients were discharged home after admission for RCVS (76.6%).
Conclusions:
Hospitalization with a recognized case of RCVS occurs in about 3 per million adults in the U.S. per year. Although majority of patients hospitalized with RCVS were discharged home, a substantial proportion had serious cerebrovascular complications.
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Affiliation(s)
| | | | - Santosh B Murthy
- Neurology, New York Presbyterian - Weill Cornell Medicine, New York, NY
| | | | - Hooman Kamel
- Neurology, New York Presbyterian - Weill Cornell Medicine, New York, NY
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11
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Magid-Bernstein J, Beaman C, Yang W, Xu K, Agarwal S, Park S, Claassen J, Connolly ES, Hod E, Roh D. Abstract WMP108: ABO Compatible Platelet Transfusion After Intracerebral Hemorrhage is Associated With Better Platelet Recovery and Outcomes Than Incompatible Transfusions. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wmp108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
There is conflicting evidence of the risks and benefits of platelet transfusions after intracerebral hemorrhage (ICH). Current practice does not necessitate the transfusion of ABO matched platelets despite evidence that platelet recovery is suboptimal in patients receiving ABO incompatible platelet transfusions.
Hypothesis:
We hypothesize that ICH patients receiving compatible platelet transfusions after ICH have better platelet recovery and outcomes compared to those receiving incompatible platelets.
Methods:
We conducted single-center, prospective cohort study of consecutive ICH patients admitted to a tertiary-referral academic medical center between 2009 and 2016. Spontaneous ICH patients who received 1 platelet transfusion within 24 hours after presentation were analyzed. Subjects were excluded if they had more than 1 platelet transfusion or non-medication related coagulopathy. Linear regression was used to evaluate the association of incompatible platelet transfusions with absolute count increment ([ACI], a continuous measure of platelet change after transfusion), adjusting for time between CBCs. Additional logistic regression analysis was performed to explore associations of ABO incompatible platelet transfusions with clinical outcomes: discharge mortality, poor modified Rankin Scale (mRS 4-6) at discharge and 3 months, after adjusting for ICH score, sex, and race.
Results:
Of the 135 patients studied, 62% received ABO compatible platelets and 38% incompatible platelet transfusions after ICH. Patients who received incompatible platelets had lower ACI than those who received compatible platelets (median -1 vs 15; standardized Beta=0.181, p=0.042). There was an association between incompatible transfusions and increased odds of discharge mortality (adjusted OR 4.208 [95%CI 1.478-11.985]; p=0.007).
Conclusions:
The majority of patients received ABO incompatible platelet transfusions, and these patients had worse platelet count recovery, higher mortality, and worse neurologic outcomes at discharge compared to those that received ABO compatible transfusions. Our findings warrant investigation into the impact of ABO compatibility in platelet transfusions and clinical outcomes after ICH.
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Affiliation(s)
| | - Charles Beaman
- Neurology, New York Presbyterian - Columbia Univ Irving Med Cntr, New York, NY
| | - Winni Yang
- Neurology, New York Presbyterian - Columbia Univ Irving Med Cntr, New York, NY
| | - Katherine Xu
- Neurology, New York Presbyterian - Columbia Univ Irving Med Cntr, New York, NY
| | - Sachin Agarwal
- Neurology, New York Presbyterian - Columbia Univ Irving Med Cntr, New York, NY
| | - Soojin Park
- Neurology, New York Presbyterian - Columbia Univ Irving Med Cntr, New York, NY
| | - Jan Claassen
- Neurology, New York Presbyterian - Columbia Univ Irving Med Cntr, New York, NY
| | - E. S Connolly
- Neurosurgery, New York Presbyterian - Columbia Univ Irving Med Cntr, New York, NY
| | - Eldad Hod
- Pathology, New York Presbyterian - Columbia Univ Irving Med Cntr, New York, NY
| | - David Roh
- Neurology, New York Presbyterian - Columbia Univ Irving Med Cntr, New York, NY
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12
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Roh DJ, Albers DJ, Magid-Bernstein J, Doyle K, Hod E, Eisenberger A, Murthy S, Witsch J, Park S, Agarwal S, Connolly ES, Elkind MSV, Claassen J. Low hemoglobin and hematoma expansion after intracerebral hemorrhage. Neurology 2019; 93:e372-e380. [PMID: 31209179 DOI: 10.1212/wnl.0000000000007820] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/08/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Studies have independently shown associations of lower hemoglobin levels with larger admission intracerebral hemorrhage (ICH) volumes and worse outcomes. We investigated whether lower admission hemoglobin levels are associated with more hematoma expansion (HE) after ICH and whether this mediates lower hemoglobin levels' association with worse outcomes. METHODS Consecutive patients enrolled between 2009 and 2016 to a single-center prospective ICH cohort study with admission hemoglobin and neuroimaging data to calculate HE (>33% or >6 mL) were evaluated. The association of admission hemoglobin levels with HE and poor clinical outcomes using modified Rankin Scale (mRS 4-6) were assessed using separate multivariable logistic regression models. Mediation analysis investigated causal associations among hemoglobin, HE, and outcome. RESULTS Of 256 patients with ICH meeting inclusion criteria, 63 (25%) had HE. Lower hemoglobin levels were associated with increased odds of HE (odds ratio [OR] 0.80 per 1.0 g/dL change of hemoglobin; 95% confidence interval [CI] 0.67-0.97) after adjusting for previously identified covariates of HE (admission hematoma volume, antithrombotic medication use, symptom onset to admission CT time) and hemoglobin (age, sex). Lower hemoglobin was also associated with worse 3-month outcomes (OR 0.76 per 1.0 g/dL change of hemoglobin; 95% CI 0.62-0.94) after adjusting for ICH score. Mediation analysis revealed that associations of lower hemoglobin with poor outcomes were mediated by HE (p = 0.01). CONCLUSIONS Further work is required to replicate the associations of lower admission hemoglobin levels with increased odds of HE mediating worse outcomes after ICH. If confirmed, an investigation into whether hemoglobin levels can be a modifiable target of treatment to improve ICH outcomes may be warranted.
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Affiliation(s)
- David J Roh
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT.
| | - David J Albers
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Jessica Magid-Bernstein
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Kevin Doyle
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Eldad Hod
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Andrew Eisenberger
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Santosh Murthy
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Jens Witsch
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Soojin Park
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Sachin Agarwal
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - E Sander Connolly
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Mitchell S V Elkind
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Jan Claassen
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
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13
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Matthews EA, Magid-Bernstein J, Sobczak E, Velazquez A, Falo CM, Park S, Claassen J, Agarwal S. Prognostic Value of the Neurological Examination in Cardiac Arrest Patients After Therapeutic Hypothermia. Neurohospitalist 2017; 8:66-73. [PMID: 29623156 DOI: 10.1177/1941874417733217] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives Current prognostication guidelines for cardiac arrest (CA) survivors predate the use of therapeutic hypothermia (TH). The prognostic value and ideal timing of the neurological examination remain unknown in the setting of TH. Design Patients (N = 291) admitted between 2007 and 2015 to Columbia University intensive care units for TH following CA had neurological examinations performed on days 1, 3, 5, and 7 postarrest. Absent pupillary light response (PLR), absent corneal reflexes (CRs), and Glasgow coma scores motor (GCS-M) no better than extension were considered poor examinations. Poor outcome was recorded as cerebral performance category score ≥3 at discharge and 1 year. Predictive values of examination maneuvers were calculated for each time point. Main Results Among the 137 survivors to day 7, sensitivities and negative predictive values were low at all time points. The PLR had false positive rates (FPRs) of 0% and positive predictive values (PPV) of 100% from day 3 onward. For the CR and GCS-M, the FPRs decreased from day 3 to 5 (9% vs 3%; 21% vs 9%), while PPVs increased (91% vs 96%; 90% vs 95%). Excluding patients who died due to withdrawal of life-sustaining therapy (WLST) did not significantly affect FPRs or PPVs, nor did assessing outcome at 1 year. Conclusions A poor neurological examination remains a strong predictor of poor outcome, both at hospital discharge and at 1 year, independent of WLST. Following TH, the predictive value of the examination is insufficient at day 3 and should be delayed until at least day 5, with some additional benefit beyond day 5.
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Affiliation(s)
| | | | - Evie Sobczak
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Cristina Maria Falo
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
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14
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Matthews EA, Magid-Bernstein J, Presciutti A, Rodriguez A, Roh D, Park S, Claassen J, Agarwal S. Categorization of survival and death after cardiac arrest. Resuscitation 2017; 114:79-82. [PMID: 28279695 DOI: 10.1016/j.resuscitation.2017.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 02/14/2017] [Accepted: 03/02/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Most cardiac arrest (CA) patients remain comatose post-resuscitation, prompting goals-of-care (GOC) conversations. The impact of these conversations on patient outcomes has not been well described. METHODS Patients (n=385) treated for CA in Columbia University ICUs between 2008-2015 were retrospectively categorized into various modes of survival and death based on documented GOC discussions. Patients were deemed "medically unstable" if there was evidence of hemodynamic instability at the time of discussion. Cerebral performance category (CPC) greater than 2 was defined as poor outcome at discharge and one-year post-arrest. RESULTS The survival rate was 31% (n=118); most commonly after early recovery without any discussions (57%, n=67), followed by survival due to family wishes despite physicians predicting poor neurological prognosis (20%, n=24), and then survival after physician/family agreement of favorable prognosis (17%, n=20). The survivors due to family wishes had significantly worse outcomes compared to the early recovery group (discharge: p=0.01; one-year: p=0.06) and agreement group (p<0.001; p<0.001), though 2 patients did achieve favorable recovery. Among nonsurvivors (n=267), withdrawal of life-sustaining therapy (WLST) while medically unstable was most common (31%; n=83), followed by death after care was capped (24%, n=65), then WLST while medically stable (17%, n=45). Death despite full support, brain death and WLST due to advanced directives were less common causes. CONCLUSIONS Most survivors due to family wishes despite poor neurological prognosis die or have poor outcomes at one-year. However, a small number achieve favorable recovery, demonstrating limitations with current prognostication methods. Among nonsurvivors, most WLST occurs while medically unstable, suggesting an overestimation of WLST due to unfavorable neurological prognosis.
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Affiliation(s)
- E A Matthews
- Columbia University College of Physicians and Surgeons, Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - J Magid-Bernstein
- Columbia University College of Physicians and Surgeons, Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - A Presciutti
- Columbia University College of Physicians and Surgeons, Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - A Rodriguez
- Columbia University College of Physicians and Surgeons, Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - D Roh
- Columbia University College of Physicians and Surgeons, Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - S Park
- Columbia University College of Physicians and Surgeons, Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - J Claassen
- Columbia University College of Physicians and Surgeons, Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - S Agarwal
- Columbia University College of Physicians and Surgeons, Department of Neurology, Columbia University Medical Center, New York, NY, United States.
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15
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Reynolds AS, Matthews E, Magid-Bernstein J, Rodriguez A, Park S, Claassen J, Agarwal S. Use of early head CT following out-of-hospital cardiopulmonary arrest. Resuscitation 2017; 113:124-127. [PMID: 28057527 DOI: 10.1016/j.resuscitation.2016.12.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 12/10/2016] [Accepted: 12/13/2016] [Indexed: 01/03/2023]
Abstract
AIM Neurological emergencies can lead to cardiac arrest, and post-arrest patients can develop life-threatening neurological abnormalities. This study aims to estimate and characterize the use of early head CT (HCT), and its potential impact on post-resuscitation management. METHODS This retrospective study analyzed 213 adults who suffered an out-of-hospital cardiac arrest (OHCA) and survived for at least 24h. Demographics were collected and arrest-related variables were documented. Timing of HCT was recorded and if abnormalities were found on HCT within 24h of resuscitation, any resulting changes in management were recorded. Outcome was measured by cerebral performance category at discharge. RESULTS Only 54% of patients who survived OHCA underwent HCT in the first 24h after resuscitation. Patients who underwent HCT were healthier and had better pre-arrest functional status and shorter duration of arrest. Acute abnormalities were found on 38% of HCT and 34% of these abnormal scans resulted in management changes. CONCLUSIONS Early HCT is not consistently performed after OHCA and may be heavily influenced by a patient's premorbid status and duration of arrest. Early HCT can demonstrate acute abnormalities that can result in significant changes in patient management.
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Affiliation(s)
- Alexandra S Reynolds
- Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Elizabeth Matthews
- Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | | | - Ashley Rodriguez
- Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York, NY, United States.
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16
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Magid-Bernstein J, Al-Mufti F, Merkler AE, Roh D, Patel S, May TL, Agarwal S, Claassen J, Park S. Unexpected Rapid Improvement and Neurogenic Stunned Myocardium in a Patient With Acute Motor Axonal Neuropathy: A Case Report and Literature Review. J Clin Neuromuscul Dis 2016; 17:135-141. [PMID: 26905914 DOI: 10.1097/cnd.0000000000000109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Acute Motor Axonal Neuropathy-type Guillain-Barré Syndrome (GBS) is a subset of GBS with either a rapidly improving or protracted course that was first described in China. We describe a 27-year-old previously healthy woman with weakness that progressed to complete tetraplegia and areflexia within 2 weeks after an upper respiratory illness. A lumbar puncture performed 4 days after onset of neurologic symptoms was inconclusive for GBS, and electromyography revealed complete motor axonal neuropathy. The patient had Mycoplasma pneumoniae in her nares and blood, and several antiganglioside antibodies in her blood. She was treated with plasmapheresis, antibiotics, and physical therapy. Her motor function and reflexes improved rapidly with treatment, and she was able to ambulate within 3 weeks. She also experienced cardiomyopathy, which improved with plasmapheresis. We report a rare case of Mycoplasma pneumonia-associated acute motor axonal neuropathy-type GBS presenting with complete tetraplegia, areflexia, and neurogenic stunned myocardium that rapidly improved with plasmapheresis.
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17
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Magid-Bernstein J, Mahajan K, Lincoln J, Ming X, Rohowsky-Kochan C. Case report: cytokine and CD4+ T-cell profiles of monozygotic twins with autism and divergent comorbidities and drug treatment. J Child Neurol 2015; 30:386-90. [PMID: 24736120 DOI: 10.1177/0883073814529821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Autism spectrum disorders are neurodevelopmental disorders that are thought to be caused by a gene-by-environment interaction and in which various immune alterations are reported. We investigate CD4(+) T-cell cytokine profiles and subpopulations in 19-year-old monozygotic twins with autism and different comorbidities. CD4(+) T cells from the twin with epilepsy produce more interferon-gamma, less interleukin-17, and have an increased interferon-γ/interleukin-4 ratio. CD4(+) T cells from the twin with multiple sclerosis exhibit a cytokine profile similar to an age and gender-matched control and a higher percentage of T regulatory (Treg) cells. The twins' mother's T cells produce very high levels of both interleukin-17 and interferon-γ. Cytokine and CD4(+) T-cell abnormalities in the twins could contribute to or be a result of the manifestation of their divergent comorbidities. A proinflammatory, autoimmune-polarized cytokine profile is observed in this unique family with autism.
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Affiliation(s)
- Jessica Magid-Bernstein
- Department of Neurology and Neurosciences, Rutgers, The State University of New Jersey, New Jersey Medical School, Newark, NJ, USA
| | - Kedar Mahajan
- Department of Neurology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - John Lincoln
- Department of Neurology, The University of Texas Medical School, Houston, TX, USA
| | - Xue Ming
- Department of Neurology and Neurosciences, Rutgers, The State University of New Jersey, New Jersey Medical School, Newark, NJ, USA
| | - Christine Rohowsky-Kochan
- Department of Neurology and Neurosciences, Rutgers, The State University of New Jersey, New Jersey Medical School, Newark, NJ, USA
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18
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Magid-Bernstein J, Rohowsky-Kochan C. Different CD4+ Treg subsets, different suppressive abilities: A comparison of CD27+CD127- and CD39+ Treg cells (65.3). The Journal of Immunology 2012. [DOI: 10.4049/jimmunol.188.supp.65.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Abstract
T regulatory (Treg) cells are important in the development of autoimmunity. They are usually identified by their expression of CD25 and Foxp3, although functionally and phenotypically diverse subsets exist. To identify human Treg subsets we analyzed expression of CD27, CD127, CD39, and CTLA4 on CD4 T cells. A CD27+CD127- phenotype correlates with high CD25 and Foxp3 expression. CD39 expression is higher on CD25hi than on CD25med/lo T cells. We co-cultured sorted Treg subsets with T effector (Teff) cells to study suppression of proliferation and cytokine production. CD4+CD25hiCD27+CD127- Treg cells were suppressive of both Teff cell proliferation and cytokine production when activated with anti-CD3 and anti-CD28. CD39+ Treg cells did not inhibit Teff cell proliferation under these culture conditions, but did suppress proliferation and cytokine production when activated with anti-CD3 and antigen-presenting cells (APCs). The varied suppressive abilities of Treg cells in these different culture conditions may be a result of the ability of APCs, but not anti-CD28, to signal through the negative costimulatory molecule CTLA4. We are currently investigating the function of CTLA4 in these Treg populations. We also examined whether these Treg subsets vary in their cytokine profile. Elucidating Treg mechanisms and subsets will enable us to clarify how Treg cells suppress, how they are altered in autoimmunity, and ultimately how this defect can be overcome to treat autoimmunity.
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19
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Magid-Bernstein J, Rohowsky-Kochan C. Phenotyping human Tregs: the key to understanding autoimmunity? (50.6). The Journal of Immunology 2011. [DOI: 10.4049/jimmunol.186.supp.50.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
T regulatory cells (Tregs) are important in the development and progression of autoimmunity. Tregs are usually identified by their expression of CD25 and Foxp3, although functionally and phenotypically diverse subsets exist. By identifying various subsets we hope to clarify their function and role in autoimmunity. We are also studying the novel cytokine IL-35, which is believed to be integral for Treg function. To identify Treg subsets we analyzed expression of CD27, CD127, and CD39 on CD4 T cells with varying CD25 levels. A CD27+CD127- phenotype correlates highly with CD25 and Foxp3 expression. CD39 expression is higher on CD4+CD25hi T cells than on CD25med/lo cells. We cultured sorted Treg subsets with T effector (Teff) cells to measure suppression. High expression of CD25 was a better marker for suppressive ability than the CD27+CD127- phenotype. CD39+ Tregs did not suppress proliferation when activated with anti-CD3 and anti-CD28, but they did inhibit IFN-γ production. Expression of the IL-35 subunits, EBI3 and p35, was observed in activated Tregs but not resting or activated induced Tregs or Teffs. Studies are ongoing to examine IL-35 in Treg subsets. Elucidating Treg mechanisms and subsets will enable us to clarify how Tregs suppress, how they are defective in autoimmunity, and ultimately how this defect can be overcome to treat autoimmunity.
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