Cerebral Venous Sinus Thrombosis Associated With Coronavirus Disease 2019: Case Report and Review of the Literature

INTRODUCTION

Coronavirus disease 2019 (COVID-19) is associated with significant risk of acute thrombosis. We present a case report of a patient with cerebral venous sinus thrombosis (CVST) associated with COVID-19 and performed a literature review of CVST associated with COVID-19 cases.

CASE REPORT

A 38-year-old woman was admitted with severe headache and acute altered mental status a week after confirmed diagnosis of COVID-19. Magnetic resonance imaging brain showed diffuse venous sinus thrombosis involving the superficial and deep veins, and diffuse edema of bilateral thalami, basal ganglia and hippocampi because of venous infarction. Her neurological exam improved with anticoagulation (AC) and was subsequently discharged home. We identified 43 patients presenting with CVST associated with COVID-19 infection. 56% were male with mean age of 51.8±18.2 years old. The mean time of CVST diagnosis was 15.6±23.7 days after onset of COVID-19 symptoms. Most patients (87%) had thrombosis of multiple dural sinuses and parenchymal changes (79%). Almost 40% had deep cerebral venous system thrombosis. Laboratory findings revealed elevated mean D-dimer level (7.14/mL±12.23 mg/L) and mean fibrinogen level (4.71±1.93 g/L). Less than half of patients had prior thrombotic risk factors. Seventeen patients (52%) had good outcomes (mRS <=2). The mortality rate was 39% (13 patients).

CONCLUSION

CVST should be in the differential diagnosis when patients present with acute neurological symptoms in this COVID pandemic. The mortality rate of CVST associated with COVID-19 can be very high, therefore, early diagnosis and prompt treatment are crucial to the outcomes of these patients.

Abstract WP293: A Prospective Validation of Stroke Network of Wisconsin (snow) Scale to Predict Large Vessel Occlusion (lvo) and Comparison With Other Stroke Scales

Background: Prior retrospective analysis confirmed that the Stroke Network of Wisconsin (SNOW) scale was highly predictive of large vessel occlusion (LVO) in patients with Acute Ischemic Stroke (AIS). In this study, we prospectively validated the SNOW scale for the identification of LVO. We also compared its accuracy to other stroke scales retrospectively applied to the same dataset.

Methods: The SNOW scale consists of 3 exam elements: expressive aphasia/Speaking difficulty (S), neglect (N) and Ocular deviation (O). The scale is positive if any one of these items is present. We prospectively evaluated all acute ischemic stroke (AIS) patients who presented within 24 hours after onset at Aurora St. Luke’s Medical Center between July 2017-February 2018 and calculated the SNOW score. We retrospectively calculated Rapid Arterial Occlusion Evaluation (RACE), the Field Assessment Stroke Triage for Emergency Destination (FAST-ED), the Vision Aphasia and Neglect Scale (VAN), the Cincinnati Prehospital Stroke Severity (CPSS), the Los Angeles Motor Scale (LAMS), the Prehospital Acute Stroke Severity Scale (PASS) for all patients. The predictive performance of all scales and National Institute of Health Stroke Scale (NIHSS) cut offs ≥6 were determined and compared. LVO was defined by total occlusions involving the intracranial internal carotid artery, middle cerebral artery (M1), or basilar arteries

Results: Among 344 AIS patients, 283 (82%) had vascular imaging and were included in the analysis. LVO was detected in 43 (15%). Positive SNOW scale showed: sensitivity = 0.84, specificity = 0.63, positive predictive value = 0.29, negative predictive value= 0.96, and area under the curve =0.74. SNOW scale had comparable accuracy to predict LVO as other scales and NIHSS cut offs ≥6. If LVO includes M2, positive SNOW had sensitivity of 0.85, specificity of 0.70, positive predictive value of 0.49, negative predictive value of 0.93 and area under the curve of 0.77. SNOW had the highest sensitivity but lowest specificity among other scales.

Conclusion: The SNOW scale is a simple and accurate tool to help identify AIS due to LVO, and it compares favorably to the other scales evaluated. A prospective validation study of the SNOW scale in the prehospital setting is underway.

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Abstract TMP66: Redefining Stroke Transport Patterns Using the SNOW Scale for Large Vessel Obstruction

Background: The SNOW (Stroke Network of Wisconsin) scale was developed to identify patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). We previously validated the SNOW scale with two retrospective and one prospective datasets of AIS patients evaluated in the Emergency Department of Aurora Health Care System hospitals. In all three studies, the SNOW scale showed a high sensitivity and accuracy and compared favorably to other stroke scales. Based on this, Milwaukee County EMS (MCEMS) implemented a new protocol incorporating the SNOW scale to prehospital triage of AIS patients: a patient with presumed AIS with a positive SNOW score, indicating LVO, paramedics are instructed to bypass the closest stroke hospital in favor of a thrombectomy capable hospital if no more than 15 minutes is added to the transport time. This is the first report of interim analysis of the data.

Methods: To be SNOW positive, a patient must exhibit at least one of the following findings: gaze deviation, expressive aphasia, or neglect. We prospectively reviewed a cohort of all suspected stroke patients MCEMS transported to the three thrombectomy capable hospitals in Milwaukee, WI, between March 1 2018 and December 31 2018. LVO was confirmed by vascular imaging and included occlusions of the intracranial internal carotid artery, middle cerebral artery (M1 and M2), anterior cerebral artery (A1 and A2), or the basilar arteries.

Results: In the first four month analysis, 108 suspected stroke transports arrived to Aurora St. Luke’s Medical Center. Of these 108, 21 (19.44%) were confirmed LVO stroke patients. The MCEMS SNOW scoring correctly identified 16 cases of LVO with a sensitivity of 76.19%, specificity of 39.98%, and accuracy (area under the receiving operating characteristics curve) of 0.5764. Aurora St. Luke’s Stroke Responders SNOW scoring correctly identified 20 LVO cases with a sensitivity of 95.24%, specificity of 58.62%, and accuracy of 0.7693. Between the EMS and Hospital SNOW scoring, all confirmed LVO patients were identified.

Conclusion: Upon analysis of interim data, the SNOW scale shows a high sensitivity and accuracy to predict LVO. Differences in EMS and Hospital scoring may be due to experience with administering the scale and the change in exam over time.

Validation of Stroke Network of Wisconsin Scale at Aurora Health Care System

BACKGROUND

The Stroke Network of Wisconsin (SNOW) scale, previously called the Pomona scale, was developed to predict large-vessel occlusions (LVOs) in patients with acute ischemic stroke (AIS). The original study showed a high accuracy of this scale. We sought to externally validate the SNOW scale in an independent cohort.

METHODS

We retrospectively reviewed and calculated the SNOW scale, the Vision Aphasia and Neglect Scale (VAN), the Cincinnati Prehospital Stroke Severity (CPSS), the Los Angeles Motor Scale (LAMS), and the Prehospital Acute Stroke Severity Scale (PASS) for all patients who were presented within 24 hours after onset at AHCS (14 hospitals) between January 2015 and December 2016. The predictive performance of all scales and several National Institute of Health Stroke Scale cutoffs (≥6) were determined and compared. LVO was defined by total occlusions involving the intracranial internal carotid artery, middle cerebral artery (MCA; M1), or basilar arteries.

RESULTS

Among 2183 AIS patients, 1381 had vascular imaging and were included in the analysis. LVO was detected in 169 (12%). A positive SNOW scale had comparable accuracy to predict LVO and showed a sensitivity of 0.80, specificity of 0.76, the positive predictive value (PPV) of 0.31, and negative predictive value of 0.96 for the detection of LVO versus CPSS ≥ 2 of 0.64, 0.87, 0.41, and 0.95. A positive SNOW scale had higher accuracy than VAN, LAMS, and PASS.

CONCLUSION

In our large stroke network cohort, the SNOW scale has promising sensitivity, specificity and accuracy to predict LVO. Future prospective studies in both prehospital and emergency room settings are warranted.

Pomona Large Vessel Occlusion Screening Tool for Prehospital and Emergency Room Settings

Background

Early identification of patients with acute ischemic strokes due to large vessel occlusions (LVO) is critical. We propose a simple risk score model to predict LVO.

Method

The proposed scale (Pomona Scale) ranges from 0 to 3 and includes 3 items: gaze deviation, expressive aphasia, and neglect. We reviewed a cohort of all acute stroke activation patients between February 2014 and January 2016. The predictive performance of the Pomona Scale was determined and compared with several National Institutes of Health Stroke Scale (NIHSS) cutoffs (≥4, ≥6, ≥8, and ≥10), the Los Angeles Motor Scale (LAMS), the Cincinnati Prehospital Stroke Severity (CPSS) scale, the Vision Aphasia and Neglect Scale (VAN), and the Prehospital Acute Stroke Severity Scale (PASS).

Results

LVO was detected in 94 of 776 acute stroke activations (12%). A Pomona Scale ≥2 had comparable accuracy to predict LVO as the VAN and CPSS scales and higher accuracy than Pomona Scale ≥1, LAMS, PASS, and NIHSS. A Pomona Scale ≥2 had an accuracy (area under the curve) of 0.79, a sensitivity of 0.86, a specificity of 0.70, a positive predictive value of 0.71, and a negative predictive value of 0.97 for the detection of LVO. We also found that the presence of either neglect or gaze deviation alone had comparable accuracy of 0.79 as Pomona Scale ≥2 to detect LVO.

Conclusion

The Pomona Scale is a simple and accurate scale to predict LVO. In addition, the presence of either gaze deviation or neglect also suggests the possibility of LVO.

Abstract TP367: Thrombolysis After Protamine Reversal Of Heparin For Acute Ischemic Stroke Post Cardiac Catheterization Case Report And Literature Review

Introduction: Most acute ischemic stroke (AIS) patients post cardiac catheterization are excluded from intravenous thrombolysis therapy because of prolonged PTT from heparin during the procedure. The outcome of these patients are unfavorable with high mortality.

Method: Case report and literature review.

Results: An 87-year-old man with diabetes mellitus, hypertension, neurofibromatosis, and hyperlipidemia underwent an elective trans-radial cardiac catheterization for abnormal stress test evaluation. He had 2 drug-eluting stents for severe stenosis of mid circumflex and right coronary arteries. He received heparin 13,000 IU during procedure. He developed acute left hemiparesis with initial NIH stroke scale (NIHSS) of 4. CT brain and CT angiogram of head and neck were unremarkable. Bedside activated clotting time (ACT) was 181. Protamine 40 mg was administered and ACT levels were at 138 when it was repeated after 30 minutes.Intravenous tissue plasminogen activator (IV tPA) was administered at 4 hours 25 minutes from his last known well. Within 15 minutes, his NIHSS was 0. Brain MRI showed no acute infarction 24 hours post stroke. To our knowledge, Only 5 AIS cases post cardiac catheterization received protamine prior IV-tPA administration. Three cases received only 0.6 mg/kg of IV- tPA dose. The mean initial NIHSS was 10 (range: 4-16) and mean discharge NIHSS was 1 (range: 0-2). They all have favorable outcomes and no intracranial hemorrhage were reported.

Conclusion: Protamine reversal of heparin for AIS post cardiac catheterization seems to be safe. Further studies are needed to confirm the therapeutic safety and efficacy of this strategy.

Abstract WP308: Low Volume of Acute Stroke Intervention in Aurora Health Care System Analysis

Introduction: Thrombectomy for acute ischemic stroke (AIS) is an important intervention, though the majority of eligible patients do not receive it. Drawing upon data from our high volume comprehensive stroke center, we identified barriers to recognizing patients with large vessel occlusion and subsequent impediments to treatment.

Methods: This is a retrospective chart review of patients presenting with AIS within 24 hours to the 14 hospitals within the AHCS between January 2015 and December 2016. Demographic, National Institutes of Health Stroke Scale (NIHSS) score, vascular imaging, and thrombectomy data were collected and analyzed. Large vessel occlusion (LVO) involved the distal internal carotid artery (ICA), middle cerebral artery (M1), or basilar artery (BA).

Results: Three thousand five hundred ninety- five AIS patients were identified. The median age was 61 years and 1863 (52%) were female. Two thousand one hundred eighty-three patients presented within 24 hours (61%): 1105 ≤ 6 hours. More than one third of AIS patients (773) did not have acute intracranial vascular imaging. Of 1410 patients with vascular imaging, 171 patients (12 %) had LVO. The site of occlusion was: M1, 86 patients (50.3%); distal ICA, 51 (30%); and BA, 27 (16%). Only 75 LVO patients (44%) had acute stroke intervention of whom 57 (77%) had mechanical thrombectomy, additional intra-arterial thrombolysis was given in 14 (19%) and 4 (5%) had intra-arterial thrombolysis as monotherapy. Successful revascularization (mTICI 2b-3) was achieved in 53 patients (70%). The main reasons that LVO patients did not receive acute stroke intervention include: late onset or unknown onset in 32 (35%), large core infarction 25 (27%), rapid improving NIHSS in 6 (7%), and unclear reason in 25 (17%),

Conclusion: There are several reasons that LVO is under recognized: a non neurologist often evaluates the patient in the ER first and they might not be familiar with stroke protocol guidelines; some LVO patients have an atypical presentation; and some patients refuse intervention. Based on our data, there is a need for continuing education of stroke care providers, particularly in this period of changing interventional guidelines.

Abstract WP216: External Validation of Pomona Large Vessel Occlusion Scale at Aurora Health Care System (AHCS)

Background: The Pomona scale was developed to predict large-vessel occlusions (LVO) in patients with acute ischemic stroke (AIS). The original study showed a high accuracy of this scale. We sought to externally validate the Pomona scale in an independent cohort.

Methods: Pomona scale includes 3 items: gaze deviation, expressive aphasia and neglect, each given 1 point when present. We retrospectively reviewed a large cohort of all acute stroke patients who presented within 24 hours after onset at AHCS ( 14 hospitals) between January 2015-December 2016. We calculated Pomona scale, the Vision Aphasia and Neglect Scale (VAN), the Cincinnati Prehospital Stroke Severity (CPSS), the Los Angeles Motor Scale (LAMS), the Prehospital Acute Stroke Severity Scale (PASS) for all patients. The predictive performance of all scales and several National Institute of Health Stroke Scale (NIHSS) cut offs (≥4, ≥6, ≥8, ≥10) were determined and compared. LVO was defined by total occlusions involving the intracranial internal carotid artery, middle cerebral artery (M1), or basilar arteries.

Results: Among 2183 AIS patients, 1410 had vascular imaging and were included in the analysis. LVO was detected in 171 (12%). Pomona scale ≥ 1 had comparable accuracy to predict LVO as Pomona scale ≥ 2, the CPSS, and NIHSS ≥6, ≥8, and ≥10. Pomona scale ≥ 1 had higher accuracy than VAN, LAMS, PASS and NIHSS ≥ 4 (area under the receiver operating characteristics curve: Pomona ≥ 1= 0.77 as a reference; VAN=0.66, P < 0.001; LAMS ≥ 4 = 0.61, P < 0.001, PASS ≥ 2= 0.68, P < 0.001 and NIHSS ≥ 4, P= 0.0025). A Pomona scale ≥ 1 had sensitivity of 0.79, specificity of 0.76 to predict LVO, positive predictive value of 0.31, and negative predictive value of 0.96 for the detection of LVO versus Pomona scale ≥ 2 of 0.57, 0.91, 0.47, and 0.94 and CPSS ≥ 2 of 0.64, 0.87, 0.41 and 0.95.

Conclusion: In our large stroke network cohort, the Pomona scale has promising sensitivity, specificity and accuracy to predict LVO. Future prospective studies in both prehospital and emergency room settings are warranted.

Abstract WP21: Extracranial Carotid Revascularization May Have Higher Mortality Rate in Acute Stroke Intervention

Background: The endovascular management of acute extracranial carotid artery (EcCA) occlusion is unclear, as hypotension, a known phenomenon with carotid revascularization (CR), may exacerbate stroke symptoms. Most studiesinclude patients with tandem intracranial occlusions requiring thrombectomy, and even in those cases, there remains variability in regards to the order and manner of endovascular therapy (e.g. extra- vs intracranial revascularization first.

Objective: We sought to compare the clinical and radiographic differences in EcCA patients who did or did not undergo proximal CR.

Methods: We identified patients screened for possible intervention with acute EcCA occlusion from our prospective stroke database from 1/2014-8/2016and abstracted their demographic, clinical, and radiographic data. We compared differences between groups using chi-square analysis.

Results: Thirty-four patients had EcCA: (10, 29% sole EcCA; 24, 71% tandem occlusions; these included 19 of our 143 (13%) patients undergoing acute stroke intervention (16 with tandem lesions, 3 without). Nine of the 16 tandem occlusion patients underwent specific CR, whereas in four we were unable to cross the EcCA, and in 3 only targeted the intracranial occlusion. The mean age was 69±14 years among 19 males and 15 females, with no intergroup differences. Most (19, 56%) received IV tPA in the whole group as well as the CR subset (7, 58%), who were loaded with antiplatelet agents afterwards; 11 underwent stent placement and 1 angioplasty alone. Although there were trends towards higher baseline and discharge National Institutes of Health Stroke scale scores (NIHSSS) among the CR group (19 vs 16 and 21 vs 18) and median discharge modified Rankin scales (5 vs 4), these were not significant (p>0.05). There were 5 deaths in both groups. As a comparison to the rest of our thrombectomy cohort, there was no significant difference in discharge NIHSSS (11 vs 13) among patients undergoing CR though there proportionately more deaths (25, 18%, no CRvs 5, 42%, CR, p<0.05).

Conclusion: These data suggest that EcCA patients should be informed of possible greater risk of mortality during acute stroke intervention. Further analyses may better identify practice standards to improve outcomes in this population.

Abstract TP251: Pomona Large Vessel Occlusion Scale for Pre-hospital and Emergency Room Settings

Background: Early detection of acute stroke with large vessel occlusion (LVO) in both pre-hospital and emergency room settings results in favorable clinical outcomes. There is still no universal guideline for LVO screening.

Method: We proposed that the presence of any of the following signs (Pomona scale): gaze deviation, expressive aphasia or neglect has a high sensitivity and accuracy to predict LVO. We reviewed a historical cohort of all acute stroke activation patients at Pomona Valley Hospital during February 2014 to January 2016. We tested Pomona scale in both groups. The predictive performance of Pomona scale was compared with different NIHSS cutoffs ( ≥4, ≥6, ≥8, ≥10), Los Angeles Motor Scale (LAMS), Cincinnati Prehospital Stroke Severity (CPSS) scale, Vision Aphasia and Neglect scale (VAN) and Prehospital Acute Stroke Severity (PASS) scale.

Results: LVO was detected in 129 of the 777 acute stroke activation (17%). Two hundred and forty-two patients had nonLVO stroke (31%). NIHSS ≥4 and Pomona scale had highest sensitivity (0.99 and 0.98 respectively) to predict LVO. LAM scale had lowest sensitivity (0.68). Pomona scale had moderate accuracy (0.61) which was comparable with VAN (0.66) and PASS (0.67). NIHSS ≥4 had the least accuracy (0.28). When Pomona scale was combined with arm weakness, it had highest accuracy (0.77) and high sensitivity (0.92) to predict LVO in acute ischemic stroke subgroup. Using various NIHSS cut off to screen for LVO had lower accuracy than using other LVO screening tools.

Conclusion: Pomona scale is very sensitive to predict LVO. It may be used as a screening tool for LVO in emergency room setting. Combination of arm weakness and Pomona scale may be used as a Pre-hospital LVO screening with moderately high accuracy.

Relationship and Characteristics of Falling at Temples among the Elderly Group in Nakhon Ratchasima, Thailand

BACKGROUND

Falls and their consequences are serious health problems among the elderly. In Thailand, temples are where the elderly often visit to pray and socialize with others. However, studies related to characteristics and severity of falls within temples are limited.

OBJECTIVE

To study characteristics of falls (falls, near falls, and fall-related injuries) and severity of falls among the elderly in temples.

MATERIAL AND METHOD

A cross-sectional analytic study. Subject is elderly population group (aged 60 and above) in the province of Nakhon Ratchasima (17 districts) who attend temples at least once a week (22 temples). The survey was conducted by questionnaires that required personal information, medical condition, frequency of fall, fall description, fall location, time of fall, and severity after a fall.

RESULTS

Total 742 subjects aged adult were screened through questionnaires. A number of 451 persons were reported to have fallen in temples, which was 60.8% of the population, whereas 76.1% of the population was said to have fallen or nearly fell. Most of the subjects have fallen only once in the past year by tripping (55%) and slipping (28.7%). Most of the falls occur outdoors (48.0%) rather than indoors (30.4%) and in the bathroom (21.6%). Some adults do not have any fall-related injuries (33.5%), though most of them experience muscle pain (27.3%). The rate of fractures among the elderly was 7.1%. A total of 117 subjects required hospitalization (25.9%). Upon being discharged from the hospital, 24.8% of the subjects were required to continue recovery at home.

CONCLUSION

The number of near falls and falls among Thai older adults in temples are quite high and very concerning. Such numbers are alarming and indicate that the elderly attending services and activities in temples require appropriate facilities and close attention from accompanying and surrounding persons. This study presented fundamental yet beneficial information which is useful for the architectural, engineering, and public health development for the elderly.

Abstract TP432: Ventriculostomy Placement Improves Outcome in Hunt and Hess Grade 3-5 Subarachnoid Hemorrhage Patients Irrespective of Hydrocephalus

Background: Cerebrospinal fluid diversion may be necessary in the acute period after subarachnoid hemorrhage (SAH) if patients develop hydrocephalus. Though there is an opinion that certain ‘severe grade’ patients, e.g. Hunt and Hess (HH) grades 3-5, should have external ventricular drain (EVD) placement, regardless of hydrocephalus, there is no firm data, leaving the decision up to the judgement of the evaluating clinical team.

Objective: We sought to measure changes in HH grades among grade 3-5 patients based on whether or not they had EVD placement.

Methods: We prospectively collect demographic, clinical, and radiographic data on our SAH patients since January 2014. We selected HH grades 3-5 patients and compared admission and discharge HH grades among groups of patients who underwent EVD placement or surgical decompression within the first 24 hours and those who did not, using chi square test.

Results: Among 54 total patients, there were 37 grades 3-5 patients (HH 3, n=26, 70.3%; HH 4, n=5, 13.5%; HH 5, n=6, 16.2%) in two groups: no EVD, n=22 (59.5%) and EVD, n=14 (37.8%, data unavailable for 1 patient). At discharge HH grades were: HH 1, n=10 (27%); HH 2, n=1 (2.7%); HH 3, n=10 (27%); HH 4, n=3 (8.1%); HH 5, n=1 (2.7%); dead, n=11 (29.7%); missing data, n=1. Mean age of 37 HH 3-5 patients was 58 years with no significant difference between the 2 groups. Hydrocephalus was seen in 11 of the 22 no EVD group and 13 of the 14 EVD group, p=0.007. Improvement in HH score between admission and discharge was seen in 10/14 EVD group, compared with 5/22 of the no EVD group, p=0.010. Worsening of HH score was found in 8/17 no EVD group (5 HH grade 5 patients excluded from this analysis), and 1 HH 4 patient (out of 14) in the EVD group, p=.014. Mortality occurred in 11/22 of the no EVD group (HH 3=5; HH 4-5=6) and 1/14 of the EVD group (HH 4, p=0.007).

Conclusion: While the presence of hydrocephalus could potentially be a determinant in the decision to place EVDs among HH grades 3-5 patients, clinical change in patients who did not have an EVD placed occurred independently of hydrocephalus. Improvement of HH grade was more frequent, while its worsening was less common, among patients who underwent EVD or surgery within the first 24 hours. Mortality of HH grade 3 patients may also be impacted with EVD placement.

Abstract TP211: Pediatric Age, but Not Treatment and Imaging Findings, Impacts Outcome in Contrast Induced Encephalopathy

Background: Contrast induced encephalopathy (CIE) following radiographic procedures, though a well-recognized complication, occurs sporadically enough that its diagnosis, prognosis, and treatment remain undefined and varied.

Objective: We sought to identify clinical and radiographic criteria as well as treatment experience vis a vis reported outcomes.

Methods: We identified case reports in PUBMED using search terms “contrast induced encephalopathy/neurotoxicity” from which we collected clinical and radiographic variables.

Results: Among 52 reports (total 79 patients, including our own unpublished 3 cases) the mean age was 60±16 years, with similar gender distribution. Multiple different contrast media were used (mean dose, 207 ±158 mL). Onset was typically immediate, though delayed cases up to 39 days later occurred. There were 3 confirmed cases (n=2, direct evidence of contrast in cerebrospinal fluid; n=1, autopsy excluded other cause of abnormality) which we classified as ‘definite CIE’. No imaging hallmark features were described in 30 patients, whom we classified as ‘possible CIE.’ The remaining 47, ‘probable CIE,’ demonstrated either diffuse edema or enhancement, with the latter being a more common finding (enhancement=33, 42% vs 11, 14%). Administered treatments included: hydration (n=31), steroids (n=10), hyperosmolar agents (n=4), anti-hypertensives (n=3), anti-convulsants (n=3), thrombolytics (n=3), hemodialysis (n=2), hemicraniectomy (n=1), and n-acetylcysteine. (n=1). There was no correlation between imaging features nor treatment modality and final outcome. Resolution occurred within 5 ±9 days. While most patients improved, 9 (11%) had no/incomplete improvement including 2 (2.5%) who expired. The 2 fatal cases occurred among the only 2 children in the entire series, p<0.001.

Conclusion: The diagnostic approach to CIE may be systemized based on the identification of hallmark radiologic findings, which, whether present or absent, do not appear to affect outcome. Though hydration and supportive remedies are most common, other treatments were not associated with hastened or worsened symptom resolution. And while the outcome of CIE among adults is generally benign, it may be fatal in children.

Abstract T P20: Rate of Endovascular Ischemic Stroke Treatment Increases with Onsite Rather than Regional Capabilities

Introduction: Currently in the US, hospitals with Neuro-Interventional capabilities represent a small proportion of all acute care facilities, and most hospitals rely on regional transfers for these services. At the same time, it is known, that having to transfer patients for Neuro-interventional stroke therapy (NIST) decreases the rate of offering this therapy, because of the time lost in the transfer process.

Objective: We sought to compare the rates of NIST being offered to patients after the inception of these services on-site, compared with the prior calendar year.

Methods: All patients presenting with neurological disturbance within 4.5 hours with a National Institutes of Health Stroke score (NIHSSS) >/= 4 undergo emergent non contrast head computed tomography (CT) and CT angiography (CTA). All patients who have no contra-indications to systemic thrombolysis receive intravenous tissue plasminogen activator (IV tPA) and in addition, those with large vessel occlusion on CTA are offered NIST.

Results: A total of 333 patients were admitted with the diagnosis of ischemic stroke (IS) in 2013. Of these 15 (4.3%) patients were transferred for NIST of which 9 received IV tPA and 6 did not. In addition, 2 patients were declined for NIST by regional centers and 2 who were transferred were unable to undergo NIST due to CT changes upon transfer. In the calendar year 2014 to date (8.5 months), among 225 IS patients, 21 (9.3%) were offered NIST, including 1 patient who was transferred from a neighboring facility. All patients offered treatment, underwent treatment. Among the 21 patients, 1 had spontaneous recanalization, another had a distal stenosis but no occlusion, and in 3, the target lesion could not be reached for intervention due to proximal carotid occlusion. Among these patients the mean initial NIHSSS was 20 and mean NIHSSS at discharge was 10. No patients experienced symptomatic hemorrhage, and one patient expired due to malignant ischemic swelling.

Conclusion: Having on-site NI capabilities doubled our rate of offering NIST. Such data may factor into a hospital’s gap analysis as to its need for NIST. Further analysis is needed to assess whether our experience of significant decline in discharge NIHSSS corresponds to long-term good functional outcome.

Salvage of distal non-target coil embolization with stent placement and intravenous eptifibatide in a ruptured, unsecured, atypical aneurysm

INTRODUCTION

Small aneurysms may be challenging to embolize. In cases of subarachnoid hemorrhage (SAH) where treatment is delayed, physicians may have to balance the risks of certain required therapies (antiplatelet agents) with the risk of rerupture. We describe a case of a technically challenging anterior cerebral artery aneurysm requiring eptifibatide infusion prior to definitive aneurysm treatment.

CASE REPORT

A 57-year-old woman with SAH, underwent coil embolization of a small fenestrated A1-A2 junction aneurysm. The procedure was complicated by downstream coil migration which was then treated with Enterprise stent placement in the pericallosal artery. This required subsequent infusion of a glycoprotein IIb/IIIa inhibitor until the aneurysm could be repaired surgically.

CONCLUSIONS

Revascularization with a stent in a distal cerebral vessel may salvage inadvertent coil migration. Although it is undesirable to administer antiplatelet agents to patients with SAH, in these circumstances short acting agents may be used.

The management of stroke in antiphospholipid syndrome

Ischemic stroke is one of the most common complications of the antiphospholipid syndrome (APS). Because of the relative lack of definitive prospective studies, there is still some debate as to whether the persistent presence of antiphospholipid antibodies (aPLs) increases the risk of recurrent stroke. There is more evidence for aPLs as a risk factor for first stroke. The mechanisms of ischemic stroke are considered to be thrombotic and embolic. APS patients with thrombotic stroke frequently have other, often conventional vascular risk factors. Transesophageal echocardiogram is strongly recommended in APS patients with ischemic stroke because of the high yield of valvular abnormalities. The appropriate management of thrombosis in patients with APS is still controversial because of limited randomized clinical trial data. This review discusses the current evidence for antithrombotic therapy in patients who are aPL positive but do not fulfill criteria for APS, and in APS patients. Alternative and emerging therapies including low molecular weight heparin, new oral anticoagulants (including direct thrombin inhibitors), hydroxychloroquine, statins, and rituximab, are also addressed.

Abstract 3892: Brooklyn AWAReness of StrokE in Diabetes Mellitus

OBJECTIVE: Diabetes mellitus (DM) is a common risk factor for stroke. Hence stroke awareness is very critical in diabetic patients. In order to design effective educational strategies for stroke intervention and prevention in this high risk group, we assessed the current status of knowledge about stroke symptoms, risk factors and activation of emergency medical services in individuals with DM.

METHOD: A hospital-based survey was conducted between February and August 2011. Subjects who have DM were interviewed at 2 sites by trained Internal medicine, Neurology residents and medical students using a structured, closed-ended questionnaire.

RESULTS: Two hundred and thirty subjects were interviewed, 64% female and 71% Caribbean-American and African-American. Seventy five percent of subjects had hypertension. Only sixty percent of subjects knew that they were high risk of stroke and only 46% had been informed by their primary care physician about this risk. More than 75% did not know their hemoglobin a1c and cholesterol levels. Stroke and diabetic ketoacidosis were the least recognized medical complications of DM (29%) while diabetic foot ulcer and diabetic nephropathy were the most recognized complications (54%). Hypertension was the most identified stroke risk factor (66%). Eighty-nine percent of respondents identified two or more stroke symptoms. Only 58% of respondents would call 911 for a stroke scenario. Subjects having DM > 10 years (p=0.02) and graduating from high school (p=0.002) were more likely to call 911, while people who had a history of kidney disease were less likely to call 911 (p=0.024). The two most common sources of information about stroke that DM patients received were from their primary care physicians (43%) and family and friends (35%).

CONCLUSION: Stroke is one of the least recognized medical complications in DM patients. Primary care physicians play a very important role of stroke education in this high risk population.

Abstract 71: Inpatient Complications, Outcomes and Predictors of Mortality in 80 Years or Older Patients Undergoing Mechanical Embolectomy for Acute Ischemic Stroke

Background and Purpose: Though utilization of mechanical embolectomy has increased in recent years, the procedure is still associated with significant morbidity and mortality in all age groups. We aimed to compare complications and outcomes after mechanical embolectomy between age groups ≥80 years and <80 years and to identify the predictors of mortality among ≥80 years.

Methods: We identified patients with acute ischemic stroke who underwent mechanical embolectomy in 2006-2009 from Nationwide Inpatient Sample (NIS) of Healthcare Cost and Utilization Project (HCUP). We compared co-morbidities and inpatient complications between age ≥80 and <80 years after sample weighting to get estimates of population. Multivariate logistic regression model was constructed to identify predictors of inpatient mortality in age ≥80 years.

Results: Of the 6723 adults who underwent mechanical embolectomy, 1298 (19%) were ≥80 years. Compared to younger, octogenerians were more likely (p<0.05) to be of female gender (68% vs. 46%) and white race (83% vs. 74%). They also had higher Elixhauser co-morbidity index (mean ± SD: 3.4 ± 1.6 vs. 3.0 ± 1.7). Unadjusted mortality rate was higher (31% vs. 22%) and rate of functional independence at discharge was lower (4% vs. 16%) for age ≥80 years. Age ≥80 years had significantly higher incidence of acute myocardial infarction (7% vs. 5%), acute kidney injury (9% vs. 6%), GI bleeding (3% vs. 2%), need for blood products transfusion (10% vs. 8%), and urinary infections (22% vs. 15%). Use of concomitant thrombolytic treatment (intravenous or intra-arterial) was higher (58% vs. 53%) in age ≥80 years. Incidence of intracranial hemorrhage (11% vs. 10%) was similar (p>0.05) between the two cohorts, as were the rates of mechanical ventilation (29% vs. 30%), gastrostomy tube placement (17% vs. 15%) and permanent tracheostomy (0.8% vs. 0.7%). After adjusting for gender, race, inter-facility transfer status, and length of hospitalization, significant predictors of in-hospital mortality for age ≥80 years were intracranial hemorrhage, sepsis, mechanical ventilation, acute myocardial infarction, acute kidney injury, and chronic pulmonary disease. Use of thrombolytic treatment did not change inpatient mortality ( Table ).

Conclusions: Morbidity and mortality in mechanical embolectomy for ischemic stroke in age ≥80 years are significantly higher compared with younger. Inpatient medical complications independently predict mortality in age ≥80 years.

Abstract 3320: There Is No Difference in Outcomes of Wake-Up Stroke vs. Stoke While Awake. An Analysis from The International Stroke Trial: A Large Prospective Randomized Trial

Background: Most acute stroke treatments have restricted therapeutic windows. Approximately a quarter of stroke patients awaken from sleep with symptoms and are precluded from intervention due to extensive times from last known well state. A single center retrospective study showed worse stroke severity and early functional outcomes after wake-up stroke (WUS) compared with stroke while awake (SWA). A population based study has shown demographic and clinical differences between WUS and SWA.

Objective: The primary aim of our study was to confirm or refute the findings from the previous studies that WUS has worse outcomes. We also compared the demographic and clinical characteristics and inpatient complications between the two groups.

Methods: Data from the International Stroke Trial were analyzed. Comparisons were made between WUS and SWA using χ 2 , student t-test, and Mann-Whitney-Wilcoxon rank sum analyses. Logistic regression analyses were performed to calculate independent effect of WUS in predicting various clinical outcomes.

Results: After excluding cases with final diagnosis other than ischemic stroke, 5,152 (29.6%) patients with WUS and 12,246 (70.4%) patients with SWA were included in the analysis. There were no significant differences in age, gender or stroke severity scale between the two groups ( Table 1 ). Atrial fibrillation was significantly less common (15.7% vs. 17.8%) and rate of lacunar stroke was higher (27.5% vs. 22.9%) in the WUS group. WUS patients had a lower unadjusted mortality at six months (20.4% vs. 22.2%, p=0.01). We found no differences in adjusted odds of inpatient mortality (OR 0.97; 95%CI:0.81-1.16), complete recovery (OR: 0.93; 95%CI:0.84-1.03), functional independence (OR:1.02; 95%CI:0.93-1.12) and mortality at six months (OR: 0.95; 95%CI:0.84-1.07) between WUS and SWA. The discharge disposition and the rates of recurrent ischemic stroke, intracranial hemorrhage, hemorrhagic transformation of ischemic stroke and major non-cerebral bleeding were also similar ( p >0.05).

Conclusions: Clinical severity and rates of inpatient complications are similar between WUS and SWA. Even though mortality at six months is lower with WUS, the effect is non-significant when controlled for confounding factors. Outcomes at six months are similar between the two groups.

Dabigatran for stroke prevention in patients with atrial fibrillation and previous stroke or transient ischemic attack: does dose matter?

Evaluation of: Diener HC, Connolly SJ, Ezekowitz MD et al.: Dabigatran compared with warfarin in patients with atrial fibrillation and previous transient ischaemic attack or stroke: a subgroup analysis of the RE-LY trial. Lancet Neurol. 9(12), 1157–1163 (2010). This study aimed to assess the efficacy and safety of daibgatran in two doses (110 and 150 mg) compared with warfarin in a prespecified subgroup analysis of patients with previous stroke or transient ischemic attack in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. There were nonsignificant risk reductions for the primary outcome (stroke and systemic embolism) for both doses of dabigatran compared with warfarin in this subgroup of patients. However, the 110-mg dose of dabigatran provided significantly greater reductions of mortality and higher net clinical benefit compared with warfarin. This was not seen in the 150-mg dose. The bleeding complication rates of this subgroup were consistent with the main RE-LY trial. In the warfarin group, patients with previous history of stroke or transient ischemic attack developed more intracranial bleeding than patients without this history, but this was not the case in dabigatran treatment groups.

Cisplatin Nephrotoxicity: A Review

BACKGROUND

Cisplatin is a major antineoplastic drug for the treatment of solid tumors, but it has dose-dependent renal toxicity.

METHODS

We reviewed clinical and experimental literature on cisplatin nephrotoxicity to identify new information on the mechanism of injury and potential approaches to prevention and/or treatment.

RESULTS

Unbound cisplatin is freely filtered at the glomerulus and taken up into renal tubular cells mainly by a transport-mediated process. The drug is at least partially metabolized into toxic species. Cisplatin has multiple intracellular effects, including regulating genes, causing direct cytotoxicity with reactive oxygen species, activating mitogen-activated protein kinases, inducing apoptosis, and stimulating inflammation and fibrogenesis. These events cause tubular damage and tubular dysfunction with sodium, potassium, and magnesium wasting. Most patients have a reversible decrease in glomerular filtration, but some have an irreversible decrease in glomerular filtration. Volume expansion and saline diuresis remain the most effective preventive strategies.

CONCLUSIONS

Understanding the mechanisms of injury has led to multiple approaches to prevention. Furthermore, the experimental approaches in these studies with cisplatin are potentially applicable to other drugs causing renal dysfunction.

Central nervous system pseudallescheriasis after near-drowning

BACKGROUND

Clinical characteristics of central nervous system (CNS) pseudallescheriasis after near-drowning have not been systematically analyzed.

METHODS

Review of cases reported in the English-language literature.

RESULTS

Sixteen patients were identified. The average period between the near-drowning episode and onset of clinical manifestations was 37 days. Common manifestations included fever, altered mental status, headache, seizures, and hemiparesis. All patients developed brain abscesses; however, imaging studies were normal at presentation in 6 patients. Cerebrospinal fluid neutrophilic pleocytosis, elevated protein, and decreased glucose were commonly observed. Most patients were treated with surgical resection and systemic amphotericin B or miconazole. Voriconazole was used in 2 patients. Twelve patients (75%) died. The average time between the near-drowning episode and death was 12 weeks. Four survivors received prompt treatment.

CONCLUSIONS

CNS pseudallescheriasis after near-drowning is highly lethal. Early diagnosis and aggressive medical and surgical interventions may improve survival.

Gitelman-like syndrome after cisplatin therapy: a case report and literature review

Background

Cisplatin is a well-known nephrotoxic antineoplastic drug. Chronic hypokalemic metabolic alkalosis with hypomagnesemia and hypocalciuria is one of the rare complications associated with its use.

Case presentation

A 42- year-old woman presented with a 20 year-history of hypokalemic metabolic alkalosis with hypomagnesemia and hypocalciuria after cisplatin-based chemotherapy for ovarian cancer. This patient has had chronic muscle aches and fatigue and has had episodic seizure-like activity and periodic paralysis. Only thirteen other patients with similar electrolyte abnormalities have been described in the literature. This case has the longest follow-up.

Conclusion

Cisplatin can cause permanent nephrotoxicity, including Gitelman-like syndrome. This drug should be considered among the possible causes of chronic unexplained electrolyte disorders.