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Flemming KD, Kim H, Hage S, Mandrekar J, Kinkade S, Girard R, Torbey M, Huang J, Huston J, Shu Y, Lanzino G, Selwyn R, Hart B, Mabray M, Feghali J, Sair HI, Narvid J, Lupo JM, Lee J, Stadnik A, Alcazar-Felix RJ, Shenkar R, Lane K, McBee N, Treine K, Ostapkovich N, Wang Y, Thompson R, Koenig JI, Carroll T, Hanley D, Awad I. Trial Readiness of Cavernous Malformations With Symptomatic Hemorrhage, Part I: Event Rates and Clinical Outcome. Stroke 2024; 55:22-30. [PMID: 38134268 PMCID: PMC10752254 DOI: 10.1161/strokeaha.123.044068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 06/02/2023] [Accepted: 10/17/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Cerebral cavernous malformation with symptomatic hemorrhage (SH) are targets for novel therapies. A multisite trial-readiness project (https://www.clinicaltrials.gov; Unique identifier: NCT03652181) aimed to identify clinical, imaging, and functional changes in these patients. METHODS We enrolled adult cerebral cavernous malformation patients from 5 high-volume centers with SH within the prior year and no planned surgery. In addition to clinical and imaging review, we assessed baseline, 1- and 2-year National Institutes of Health Stroke Scale, modified Rankin Scale, European Quality of Life 5D-3 L, and patient-reported outcome-measurement information system, Version 2.0. SH and asymptomatic change rates were adjudicated. Changes in functional scores were assessed as a marker for hemorrhage. RESULTS One hundred twenty-three, 102, and 69 patients completed baseline, 1- and 2-year clinical assessments, respectively. There were 21 SH during 178.3 patient years of follow-up (11.8% per patient year). At baseline, 62.6% and 95.1% of patients had a modified Rankin Scale score of 1 and National Institutes of Health Stroke Scale score of 0 to 4, respectively, which improved to 75.4% (P=0.03) and 100% (P=0.06) at 2 years. At baseline, 74.8% had at least one abnormal patient-reported outcome-measurement information system, Version 2.0 domain compared with 61.2% at 2 years (P=0.004). The most common abnormal European Quality of Life 5D-3 L domains were pain (48.7%), anxiety (41.5%), and participation in usual activities (41.4%). Patients with prospective SH were more likely than those without SH to display functional decline in sleep, fatigue, and social function patient-reported outcome-measurement information system, Version 2.0 domains at 2 years. Other score changes did not differ significantly between groups at 2 years. The sensitivity of scores as an SH marker remained poor at the time interval assessed. CONCLUSIONS We report SH rate, functional, and patient-reported outcomes in trial-eligible cerebral cavernous malformation with SH patients. Functional outcomes and patient-reported outcomes generally improved over 2 years. No score change was highly sensitive or specific for SH and could not be used as a primary end point in a trial.
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Affiliation(s)
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesiology and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Stephanie Hage
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Jay Mandrekar
- Department of Biostatistics, Mayo Clinic, Rochester, MN USA
| | - Serena Kinkade
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Michel Torbey
- Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yunhong Shu
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Reed Selwyn
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Blaine Hart
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Marc Mabray
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | - Haris I. Sair
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jared Narvid
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Janine M. Lupo
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Justine Lee
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Roberto J. Alcazar-Felix
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Robert Shenkar
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Karen Lane
- Brain Injury Outcomes Unit, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | - Nichole McBee
- Brain Injury Outcomes Unit, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | - Kevin Treine
- Brain Injury Outcomes Unit, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | - Noeleen Ostapkovich
- Brain Injury Outcomes Unit, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | - Ying Wang
- Brain Injury Outcomes Unit, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | - Richard Thompson
- Brain Injury Outcomes Unit, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | - James I. Koenig
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Timothy Carroll
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Daniel Hanley
- Brain Injury Outcomes Unit, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
| | - Issam Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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Carlson AP, Davis HT, Jones T, Brennan KC, Torbey M, Ahmadian R, Qeadan F, Shuttleworth CW. Is the Human Touch Always Therapeutic? Patient Stimulation and Spreading Depolarization after Acute Neurological Injuries. Transl Stroke Res 2023; 14:160-173. [PMID: 35364802 PMCID: PMC9526760 DOI: 10.1007/s12975-022-01014-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 01/18/2022] [Revised: 02/21/2022] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
Touch and other types of patient stimulation are necessary in critical care and generally presumed to be beneficial. Recent pre-clinical studies as well as randomized trials assessing early mobilization have challenged the safety of such routine practices in patients with acute neurological injury such as stroke. We sought to determine whether patient stimulation could result in spreading depolarization (SD), a dramatic pathophysiological event that likely contributes to metabolic stress and ischemic expansion in such patients. Patients undergoing surgical intervention for severe acute neurological injuries (stroke, aneurysm rupture, or trauma) were prospectively consented and enrolled in an observational study monitoring SD with implanted subdural electrodes. Subjects also underwent simultaneous video recordings (from continuous EEG monitoring) to assess for physical touch and other forms of patient stimulation (such as suctioning and positioning). The association of patient stimulation with subsequent SD was assessed. Increased frequency of patient stimulation was associated with increased risk of SD (OR = 4.39 [95%CI = 1.71-11.24]). The overall risk of SD was also increased in the 60 min following patient stimulation compared to times with no stimulation (OR = 1.19 [95%CI = 1.13-1.26]), though not all subjects demonstrated this effect individually. Positioning of the subject was the subtype of stimulation with the strongest overall effect on SD (OR = 4.92 [95%CI = 3.74-6.47]). We conclude that in patients with some acute neurological injuries, touch and other patient stimulation can induce SD (PS-SD), potentially increasing the risk of metabolic and ischemic stress. PS-SD may represent an underlying mechanism for observed increased risk of early mobilization in such patients.
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Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, Neurosciences, and Neurology, University of New Mexico, NM, Albuquerque, USA.
| | - Herbert T Davis
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Thomas Jones
- Department of Psychiatry, University of New Mexico, Albuquerque, NM, USA
| | - K C Brennan
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Michel Torbey
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Rosstin Ahmadian
- University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Fares Qeadan
- Department of Public Health Sciences, Loyola University Chicago, Chicago, IL, USA
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Varela S, Carrera D, Elazim AA, Robinson MB, Torbey M, Carlson AP. Continuous Tissue Plasminogen Activator Infusion Using a Minimally Invasive Irrigating Catheter for the Treatment of Intraparenchymal Hemorrhage Within the Basal Ganglia: Case Reports. Oper Neurosurg (Hagerstown) 2022; 23:e387-e391. [PMID: 36227254 PMCID: PMC10586848 DOI: 10.1227/ons.0000000000000408] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Received: 03/30/2022] [Accepted: 06/28/2022] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Intraparenchymal hemorrhage (IPH) is a debilitating and highly morbid type of stroke with limited effective treatment modalities. Minimally invasive evacuation with tissue plasminogen activator (rt-PA) has demonstrated promise for mortality/functional improvements with adequate clot volume reduction. In this study, we report 2 cases of continuous rt-PA infusion using a closed circuit, dual lumen catheter, and irrigation system (IRRAflow) for IPH treatment. CLINICAL PRESENTATION A 55-year-old man was admitted for acute onset left hemiparesis; he was found to have right basal ganglia IPH. He was treated with continuous rt-PA irrigation using the IRRAflow device, at a rate of 30 mL/h for 119 hours, with a total volume reduction of 87.8 mL and post-treatment volume of 1.2 mL. At 3-month follow-up, he exhibited a modified Rankin score of 4 and improved hemiparesis. A 39-year-old woman was admitted for acute onset left facial droop, left hemianopsia, and left hemiparesis; she was diagnosed with a right basal ganglia IPH. She was treated with drainage and continuous rt-PA irrigation at 30 mL/h for 24 hours, with a total hematoma volume reduction of 41 mL and with a final post-treatment volume of 9.1 mL. At 3-month follow-up, she exhibited a modified Rankin score of 3 with some improvement in left hemiparesis. CONCLUSION Continuous rt-PA infusion using a minimally invasive catheter with saline irrigation was feasible and resulted in successful volume reduction in 2 patients with IPH. This technique is similar to the Minimally Invasive Surgery Plus rt-PA for Intracerebral Hemorrhage Evacuation (MISTIE) approach but offers the potential advantages of less breaks in the sterile circuit, continuous intracranial pressure monitoring, and may provide more efficient clot lysis compared with intermittent bolusing.
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Affiliation(s)
- Samantha Varela
- School of Medicine, University of New Mexico (UNM), Albuquerque, New Mexico, USA
| | - Diego Carrera
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, New Mexico, USA
| | - Ahmed Abd Elazim
- Department of Neurology, University of New Mexico Hospital (UNMH), Albuquerque, New Mexico, USA
| | - Myranda B. Robinson
- School of Medicine, University of New Mexico (UNM), Albuquerque, New Mexico, USA
| | - Michel Torbey
- Department of Neurology, University of New Mexico Hospital (UNMH), Albuquerque, New Mexico, USA
| | - Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, New Mexico, USA
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Meadows C, Davis H, Mohammad L, Shuttleworth CW, Torbey M, Zhu Y, Alsarah AA, Carlson AP. Correction to: Spreading Depolarization After Chronic Subdural Hematoma Evacuation: Associated Clinical Risk Factors and Influence on Clinical Outcome. Neurocrit Care 2021; 36:332. [PMID: 34796430 DOI: 10.1007/s12028-021-01377-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Christine Meadows
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Herbert Davis
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Laila Mohammad
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - C William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Michel Torbey
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Yiliang Zhu
- Clinical Translational Science Center, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Ali A Alsarah
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA.
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Kim H, Flemming KD, Nelson JA, Lui A, Majersik JJ, Cruz MD, Zabramski J, Trevizo O, Lanzino G, Zafar A, Torbey M, Mabray MC, Robinson M, Narvid J, Lupo J, Thompson RE, Hanley DF, McBee N, Treine K, Ostapkovich N, Stadnik A, Piedad K, Hobson N, Carroll T, Shkoukani A, Carrión-Penagos J, Mendoza-Puccini C, Koenig JI, Awad I. Baseline Characteristics of Patients With Cavernous Angiomas With Symptomatic Hemorrhage in Multisite Trial Readiness Project. Stroke 2021; 52:3829-3838. [PMID: 34525838 DOI: 10.1161/strokeaha.120.033487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Brain cavernous angiomas with symptomatic hemorrhage (CASH) have a high risk of neurological disability from recurrent bleeding. Systematic assessment of baseline features and multisite validation of novel magnetic resonance imaging biomarkers are needed to optimize clinical trial design aimed at novel pharmacotherapies in CASH. METHODS This prospective, multicenter, observational cohort study included adults with unresected, adjudicated brain CASH within the prior year. Six US sites screened and enrolled patients starting August 2018. Baseline demographics, clinical and imaging features, functional status (modified Rankin Scale and National Institutes of Health Stroke Scale), and patient quality of life outcomes (Patient-Reported Outcomes Measurement Information System-29 and EuroQol-5D) were summarized using descriptive statistics. Patient-Reported Outcomes Measurement Information System-29 scores were standardized against a reference population (mean 50, SD 10), and one-sample t test was performed for each domain. A subgroup underwent harmonized magnetic resonance imaging assessment of lesional iron content with quantitative susceptibility mapping and vascular permeability with dynamic contrast-enhanced quantitative perfusion. RESULTS As of May 2020, 849 patients were screened and 110 CASH cases enrolled (13% prevalence of trial eligible cases). The average age at consent was 46±16 years, 53% were female, 41% were familial, and 43% were brainstem lesions. At enrollment, ≥90% of the cohort had independent functional outcome (modified Rankin Scale score ≤2 and National Institutes of Health Stroke Scale score <5). However, perceived health problems affecting quality of life were reported in >30% of patients (EuroQol-5D). Patients had significantly worse Patient-Reported Outcomes Measurement Information System-29 scores for anxiety (P=0.007), but better depression (P=0.002) and social satisfaction scores (P=0.012) compared with the general reference population. Mean baseline quantitative susceptibility mapping and permeability of CASH lesion were 0.45±0.17 ppm and 0.39±0.31 mL/100 g per minute, respectively, which were similar to historical CASH cases and consistent across sites. CONCLUSIONS These baseline features will aid investigators in patient stratification and determining the most appropriate outcome measures for clinical trials of emerging pharmacotherapies in CASH.
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Affiliation(s)
- Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco. (H.K., J.A.N., A.L.).,Department of Epidemiology and Biostatistics, University of California, San Francisco. (H.K.)
| | | | - Jeffrey A Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco. (H.K., J.A.N., A.L.)
| | - Avery Lui
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco. (H.K., J.A.N., A.L.)
| | - Jennifer J Majersik
- Department of Neurology, University of Utah, Salt Lake City (J.J.M., M.D.C.)
| | - Michael Dela Cruz
- Department of Neurology, University of Utah, Salt Lake City (J.J.M., M.D.C.)
| | - Joseph Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (J.Z., O.T.)
| | - Odilette Trevizo
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (J.Z., O.T.)
| | | | - Atif Zafar
- Department of Neurology, University of Toronto, Canada (A.Z.)
| | - Michel Torbey
- Department of Neurology, University of New Mexico, Albuquerque. (M.T.)
| | - Marc C Mabray
- Department of Radiology, University of New Mexico, Albuquerque. (M.C.M.)
| | - Myranda Robinson
- Department of Neurosurgery, University of New Mexico, Albuquerque. (M.R.)
| | - Jared Narvid
- Department of Radiology and Biomedical Imaging, University of California, San Francisco. (J.N., J.L.)
| | - Janine Lupo
- Department of Radiology and Biomedical Imaging, University of California, San Francisco. (J.N., J.L.)
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD. (R.E.T.)
| | - Daniel F Hanley
- Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD. (D.F.H., N.M., K.T., N.O.)
| | - Nichol McBee
- Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD. (D.F.H., N.M., K.T., N.O.)
| | - Kevin Treine
- Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD. (D.F.H., N.M., K.T., N.O.)
| | - Noeleen Ostapkovich
- Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD. (D.F.H., N.M., K.T., N.O.)
| | - Agnieszka Stadnik
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Kristina Piedad
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Nicholas Hobson
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Timothy Carroll
- Department of Diagnostic Radiology, University of Chicago, IL. (T.C.)
| | - Abdallah Shkoukani
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Julián Carrión-Penagos
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Carolina Mendoza-Puccini
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD. (C.M.-P.)
| | - James I Koenig
- Division of Neuroscience, National Institute of Neurological Disorders and Stroke, Bethesda, MD. (J.I.K.)
| | - Issam Awad
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
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Yang LY, Bhaskar K, Thompson J, Duval K, Torbey M, Yang Y. Non-invasive vagus nerve stimulation reduced neuron-derived IL-1β and neuroinflammation in acute ischemic rat brain. Brain Hemorrhages 2021. [DOI: 10.1016/j.hest.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Chen SY, Thompson-Leduc P, Sawyer RN, Fakih I, Cheung HC, Macheca M, Kirson NY, Torbey M. Outcomes and resource use of patients with large hemispheric infarction and cerebral edema: analysis of real-world data. Curr Med Res Opin 2021; 37:781-788. [PMID: 33685308 DOI: 10.1080/03007995.2021.1900090] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Large hemispheric infarction (LHI) is associated with a high likelihood of the evolution of life-threatening edema. Few studies have assessed real-world clinical outcomes and management strategies among patients with LHI. The objective of this study was to describe the management, in-hospital outcomes, and direct healthcare resource burden of patients with LHI, as well as those of patients with subsequent cerebral edema. METHODS This observational, retrospective cohort study analyzed de-identified data from US adult patients using the IBM MarketScan Hospital Drug Database (Q4-2015 to Q4-2017). Patients were included in the "Possible LHI" or the "Other Ischemic Strokes" cohorts using ICD-10 diagnosis codes. Patients with possible LHI were further categorized into "LHI with Edema" and "LHI without Edema" subgroups using diagnosis and procedure codes. Select clinical and economic outcomes were compared between cohorts and subgroups using multivariable regressions. RESULTS Of 79,201 eligible encounters with ischemic strokes, 11,772 unique patients were assigned to the Possible LHI cohort while 67,429 were assigned to the Other Ischemic Strokes cohort. Among patients with possible LHI, 869 (7%) were assigned to the LHI with Edema subgroup and 10,903 (93%) were assigned to the LHI without Edema subgroup. Patients in the Possible LHI cohort had longer hospital stays (mean difference [MD] [95%CI] = 2.6 [2.4;2.8] days), higher total facility charges (MD [95%CI] = $28,656 [26,794;30,524]), and higher odds of death (odds ratio [95%CI] = 2.2 [2.0;2.4]) than the Other Ischemic Strokes cohort. Among patients with possible LHI, the incremental clinical and resource burden was further exacerbated in the subgroup of patients with edema (hospital days: MD [95%CI] = 5.0 [3.9;6.2] days; total facility charges: MD [95%CI] = $59,585 [50,816;67,583]; mortality: odds ratio [95%CI] = 10.3 [8.5;12.4]). CONCLUSIONS Among patients with ischemic strokes, LHI was associated with increased clinical management and direct healthcare resource burden in real-world hospital settings. The burden was substantially increased among patients who developed cerebral edema.
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Affiliation(s)
| | | | - Robert N Sawyer
- Department of Neurology, University at Buffalo, Buffalo, NY, USA
| | | | | | | | | | - Michel Torbey
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
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Zarean E, Lattanzi S, Looha MA, Napoli MD, Chou SHY, Jafarli A, Torbey M, Divani AA. Glycemic Gap Predicts in-Hospital Mortality in Diabetic Patients with Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105669. [PMID: 33636475 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105669] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/26/2021] [Accepted: 02/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE The relationship between admission hyperglycemia and intracerebral hemorrhage (ICH) outcome remains controversial. Glycemic gap (GG) is a superior indicator of glucose homeostatic response to physical stress compared to admission glucose levels. We aimed to evaluate the association between GG and in-hospital mortality in ICH. METHODS We retrospectively identified consecutive patients hospitalized for spontaneous ICH at the 2 healthcare systems in the Twin Cities area, MN, between January 2008 and December 2017. Patients without glycosylated hemoglobin (HbA1c) test or those admitted beyond 24 hours post-ICH were excluded. Demographics, medical history, admission tests, and computed tomography data were recorded. GG was computed using admission glucose level minus HbA1c-derived average glucose. The association between GG and time to in-hospital mortality was evaluated by Cox regression analysis. Receiver operating characteristic (ROC) analysis with the DeLong test was used to evaluate the ability of GG to predict in-hospital death. RESULTS Among 345 included subjects, 63 (25.7%) died during the hospital stay. Compared with survivors, non-survivors presented with a lower Glasgow coma scale score, larger hematoma volume, and higher white blood cells count, glucose, and GG levels at admission (p<0.001). GG remained an independent predictor of in-hospital mortality after adjusting for known ICH outcome predictors and potential confounders [adjusted hazard ratio: 1.09, 95% confidence interval (CI): 1.02-1.18, p = 0.018]. GG showed a good discriminative power (area under the ROC curve: 0.75, 95% CI: 0.68-0.82) in predicting in-hospital death and performed better than admission glucose levels in diabetic patients (p = 0.030 for DeLong test). CONCLUSIONS Admission GG is associated with the risk of in-hospital mortality and can potentially represent a useful prognostic biomarker for ICH patients with diabetes.
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Affiliation(s)
- Elaheh Zarean
- Department of Neurology, University of New Mexico, NM, USA; Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Sherry H-Y Chou
- Departments of Critical Care Medicine, Neurology, & Neurosurgery, University of Pittsburgh, PA, USA.
| | - Alibay Jafarli
- Department of Neurology, University of New Mexico, NM, USA.
| | - Michel Torbey
- Department of Neurology, University of New Mexico, NM, USA.
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Owen B, Akbik O, Torbey M, Davis H, Carlson AP. Incidence and outcomes of intracerebral haemorrhage with mechanical compression hydrocephalus. Stroke Vasc Neurol 2021; 6:328-336. [PMID: 33419863 PMCID: PMC8485232 DOI: 10.1136/svn-2020-000401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/10/2020] [Accepted: 08/14/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction Intracerebral haemorrhage (ICH) within deep structures adjacent to the third ventricle is associated with worse outcomes when compared with lobar ICH due to the critical role of deep nuclei in normal neurological functioning. New evidence suggests another contributing factor to poor outcome is obstruction of cerebrospinal fluid outflow by clot burden causing mechanical compression of the third ventricle. The authors reviewed the incidence and outcomes of mechanical compression ICH in order to identify this high-risk group which may potentially benefit from minimally invasive evacuation. Methods Patients with spontaneous, non-traumatic, supratentorial ICH were identified retrospectively over a 30-month period. CT imaging was reviewed to assess location of the ICH, volume of the ICH, presence of hydrocephalus requiring external ventricular drain (EVD) placement, and time to clearing of the third ventricle. Hydrocephalus was then categorised as due to ‘primarily intraventricular haemorrhage (IVH)’, ‘primarily mechanical compression’ or ‘mixed’. Functional outcomes at discharge were assessed using the modified Rankin Score (mRS). Results 287 patients met inclusion criteria, of which 39 (13.5%) patients developed hydrocephalus that required EVD. EVD patients had significantly higher mRS at discharge (p≤0.001) when compared with the non-EVD group. Lobar location was associated with lower odds of poor outcome compared with thalamic location (OR 0.107–0.560). Mechanical compression hydrocephalus was associated with poor outcome when compared with the primary IVH hydrocephalus subgroup (p=0.037) as well as longer time to clearing of the third ventricle (p=0.006). Conclusions Mechanical obstruction requiring EVD occurs in approximately (21/287) 7.3% of all patients with spontaneous supratentorial ICH. It is unknown if the worse morbidity in these subjects is purely related to damage to deep structures surrounding the third ventricle or if secondary damage from hydrocephalus could be mitigated with targeted minimally invasive clot evacuation.
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Affiliation(s)
- Bryce Owen
- School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Omar Akbik
- Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Michel Torbey
- Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Herbert Davis
- Division of Epidemiology, Biostatistics, and Preventive Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Andrew P Carlson
- Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
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Divani AA, Andalib S, Biller J, Di Napoli M, Moghimi N, Rubinos CA, O'Hana Nobleza C, Sylaja PN, Toledano M, Lattanzi S, McCullough LD, Cruz-Flores S, Torbey M, Azarpazhooh MR. Correction to: Central Nervous System Manifestations Associated with COVID-19. Curr Neurol Neurosci Rep 2020; 20:66. [PMID: 33184674 PMCID: PMC7661013 DOI: 10.1007/s11910-020-01086-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The original version contained incorrect formatting of Dr. Napolis. His first name should be Mario and his last name should be Di Napoli.
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Affiliation(s)
- Afshin A Divani
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, NM, USA.
| | - Sasan Andalib
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, NM, USA.,Research Unit of Clinical Physiology and Nuclear Medicine, Department of Nuclear Medicine Odense University Hospital, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Neuroscience Research Center, Department of Neurosurgery, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - José Biller
- Department of Neurology, Loyola University, Stritch School of Medicine, Maywood, IL, USA
| | - Mario Di Napoli
- Department of Neurology and Stroke Unit, San Camillo de' Lellis District General Hospital, Rieti, Italy
| | - Narges Moghimi
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Clio A Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | | | - P N Sylaja
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | | | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Louise D McCullough
- Department of Neurology, McGovern Medical School, The University of Texas at Houston, Houston, TX, USA
| | - Salvador Cruz-Flores
- Neurology Department, Texas Tech Health University, Health Sciences Center, El Paso, El Paso, TX, USA
| | - Michel Torbey
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - M Reza Azarpazhooh
- Departments of Clinical Neurological sciences, Western University, London, Canada
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11
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Divani AA, Andalib S, Di Napoli M, Lattanzi S, Hussain MS, Biller J, McCullough LD, Azarpazhooh MR, Seletska A, Mayer SA, Torbey M. Coronavirus Disease 2019 and Stroke: Clinical Manifestations and Pathophysiological Insights. J Stroke Cerebrovasc Dis 2020; 29:104941. [PMID: 32689643 PMCID: PMC7214348 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104941] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/04/2020] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Some COVID-19 patients have exhibited widespread neurological manifestations including stroke. Acute ischemic stroke, intracerebral hemorrhage, and cerebral venous sinus thrombosis have been reported in patients with COVID-19. COVID-19-associated coagulopathy is likely caused by inflammation. Resultant ACE2 down-regulation causes RAS imbalance, which may lead to stroke.
Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global health threat. Some COVID-19 patients have exhibited widespread neurological manifestations including stroke. Acute ischemic stroke, intracerebral hemorrhage, and cerebral venous sinus thrombosis have been reported in patients with COVID-19. COVID-19-associated coagulopathy is increasingly recognized as a result of acute infection and is likely caused by inflammation, including inflammatory cytokine storm. Recent studies suggest that axonal transport of SARS-CoV-2 to the brain can occur via the cribriform plate adjacent to the olfactory bulb that may lead to symptomatic anosmia. The internalization of SARS-CoV-2 is mediated by the binding of the spike glycoprotein of the virus to the angiotensin-converting enzyme 2 (ACE2) on cellular membranes. ACE2 is expressed in several tissues including lung alveolar cells, gastrointestinal tissue, and brain. The aim of this review is to provide insights into the clinical manifestations and pathophysiological mechanisms of stroke in COVID-19 patients. SARS-CoV-2 can down-regulate ACE2 and, in turn, overactivate the classical renin-angiotensin system (RAS) axis and decrease the activation of the alternative RAS pathway in the brain. The consequent imbalance in vasodilation, neuroinflammation, oxidative stress, and thrombotic response may contribute to the pathophysiology of stroke during SARS-CoV-2 infection.
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Affiliation(s)
- Afshin A Divani
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque 87131, New Mexico, USA.
| | - Sasan Andalib
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque 87131, New Mexico, USA; Research Unit of Clinical Physiology and Nuclear Medicine, Department of Nuclear Medicine, Odense University Hospital, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Neuroscience Research Center, Department of Neurosurgery, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran.
| | - Mario Di Napoli
- Department of Neurology and Stroke Unit, San Camillo de' Lellis District General Hospital, Rieti, Italy.
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
| | - M Shazam Hussain
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - José Biller
- Department of Neurology, Loyola University, Stritch School of Medicine, Maywood, IL, USA.
| | - Louise D McCullough
- Department of Neurology, McGovern Medical School, The University of Texas at Houston, Houston, TX, USA.
| | - M Reza Azarpazhooh
- Department of Clinical Neurological Sciences and Stroke Prevention & Atherosclerosis Research Center, Western University, London, Canada.
| | - Alina Seletska
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque 87131, New Mexico, USA.
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, New York Medical College, Westchester Medical Center Health Network, Valhalla, NY, USA.
| | - Michel Torbey
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque 87131, New Mexico, USA.
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12
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Abootalebi S, Aertker BM, Andalibi MS, Asdaghi N, Aykac O, Azarpazhooh MR, Bahit MC, Barlinn K, Basri H, Shahripour RB, Bersano A, Biller J, Borhani-Haghighi A, Brown RD, Campbell BC, Cruz-Flores S, De Silva DA, Di Napoli M, Divani AA, Edgell RC, Fifi JT, Ghoreishi A, Hirano T, Hong KS, Hsu CY, Huang JF, Inoue M, Jagolino AL, Kapral M, Kee HF, Keser Z, Khatri R, Koga M, Krupinski J, Liebeskind DS, Liu L, Ma H, Maud A, McCullough LD, Meyer DM, Mifsud V, Morovatdar N, Nilanont Y, Oxley TJ, Özdemir AÖ, Pandian J, Pantoni L, Papamitsakis NIH, Parry-Jones A, Phan T, Rodriguez G, Romano JG, Sabaa-Ayoun Z, Saber H, Sasannezhad P, Saver JL, Scharf E, Shuaib A, Silver B, Singhal S, Smith CJ, Stranges S, Sylaja PN, Torbey M, Toyoda K, Tsivgoulis G, Wasay M, Yassi N, Yoshimoto T, Zamani B, Zand R. Call to Action: SARS-CoV-2 and CerebrovAscular DisordErs (CASCADE). J Stroke Cerebrovasc Dis 2020; 29:104938. [PMID: 32807412 PMCID: PMC7205703 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104938] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 12/31/2022] Open
Abstract
Background and purpose The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic. Methods This is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center. Conclusion The proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.
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Affiliation(s)
- Shahram Abootalebi
- Dr. Everett Chalmers Regional Hospital, Dalhousie University, New Brunswick, Canada.
| | - Benjamin M Aertker
- Department of Neurology, UTHealth McGovern Medical School, The University of Texas at Houston, Houston, Texas, USA.
| | - Mohammad Sobhan Andalibi
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, Florida, USA.
| | - Ozlem Aykac
- Department of Neurology and Neurocritical Care, Eskisehir Osmangazi University, Eskişehir, Turkey
| | - M Reza Azarpazhooh
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - M Cecilia Bahit
- Chief of Cardiology, INECO Neurociencias, Rosario, Argentina
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany.
| | - Hamidon Basri
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.
| | | | - Anna Bersano
- Fondazione Istituto Neurologico 'Carlo Besta', Milan, Italy.
| | - Jose Biller
- Department of Neurology, Loyola University Health System, Stritch School of Medicine, Chicago, USA.
| | | | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Bruce Cv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.
| | | | | | - Mario Di Napoli
- Department of Neurology and Stroke Unit, San Camillo de' Lellis General District Hospital, Rieti, Italy; Neurological Section, Neuro-epidemiology Unit, SMDN-Centre for Cardiovascular Medicine and Cerebrovascular Disease Prevention, Sulmona, L'Aquila, Italy.
| | - Afshin A Divani
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Randall C Edgell
- Department of Neurology, Souers Stroke Institute, Saint Louis University, USA
| | - Johanna T Fifi
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Abdoreza Ghoreishi
- Department of Neurology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Japan.
| | - Keun-Sik Hong
- Department of Neurology, Inje University, Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taipei, Taichung.
| | | | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Amanda L Jagolino
- Department of Neurology, UTHealth McGovern Medical School, The University of Texas at Houston, Houston, Texas, USA.
| | - Moira Kapral
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada.
| | - Hoo Fan Kee
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Zafer Keser
- Department of Neurology, UTHealth McGovern Medical School, The University of Texas at Houston, Houston, Texas, USA.
| | - Rakesh Khatri
- Neurology Department, Texas Tech Health University, El Paso, Texas, USA.
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Jerzy Krupinski
- Department of Neurology, Hospital Universitari MutuaTerrassa, Terrassa (Barcelona), Spain; Department of Life Sciences, CBS, Manchester Metropolitan University, Manchester, UK.
| | | | - Liping Liu
- Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Henry Ma
- Department of Neurology, Monash Health and Department of Medicine, School of Clinical Sciences Monash University, Australia
| | - Alberto Maud
- Neurology Department, Texas Tech Health University, El Paso, Texas, USA
| | - Louise D McCullough
- Department of Neurology, UTHealth McGovern Medical School, The University of Texas at Houston, Houston, Texas, USA.
| | | | | | - Negar Morovatdar
- Clinical Research Development Unit, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Yongchai Nilanont
- Siriraj Stroke Center, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thomas J Oxley
- Department of Neurosurgery, Mount Sinai Hospital, New York, USA.
| | - Atilla Özcan Özdemir
- Department of Neurology and Neurocritical Care, Eskisehir Osmangazi University, Eskişehir, Turkey
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, India
| | - Leonardo Pantoni
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Milan, Italy.
| | | | - Adrian Parry-Jones
- Manchester Centre for Clinical Neurosciences, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, Salford, UK.
| | - Thanh Phan
- Department of Neurology, Monash Health and Department of Medicine, School of Clinical Sciences Monash University, Australia.
| | - Gustavo Rodriguez
- Neurology Department, Texas Tech Health University, El Paso, Texas, USA
| | - Jose G Romano
- Department of Neurology, University of Miami, Miami, Florida, USA.
| | - Ziad Sabaa-Ayoun
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario Canada.
| | - Hamidreza Saber
- David Geffen School of Medicine, Comprehensive Stroke Center, Department of Neurology, University of California, Los Angeles, USA.
| | - Payam Sasannezhad
- Department of Neurology, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Jeffrey L Saver
- Department of Neurology, Geffen School of Medicine, UCLA, USA.
| | - Eugene Scharf
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
| | - Shaloo Singhal
- Department of Neurology, Monash Health and Department of Medicine, School of Clinical Sciences Monash University, Australia
| | - Craig J Smith
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, UK; Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK.
| | - Saverio Stranges
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg.
| | - P N Sylaja
- Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum 695 011, Kerala, India
| | - Michel Torbey
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA.
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia.
| | - Takeshi Yoshimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Babak Zamani
- Neurology department of Iran University of Medical Sciences, Tehran, Iran
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania, USA
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Chen SY, Thompson-Leduc P, Sawyer RN, Macheca M, Fakih I, Cheung HC, Kirson NY, Torbey M. Abstract WP370: Inpatient Outcomes and Resource Utilization Among Patients With Large Hemispheric Infarction Who Developed Cerebral Edema: An Analysis of U.S. Real-World Data. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp370] [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:
Patients with large hemispheric infarction (LHI) may suffer from life-threatening complications, including cerebral edema. Published data among these patients in real-world settings are limited. This study describes inpatient outcomes and resource utilization associated with cerebral edema among hospitalized patients with LHI.
Methods:
A retrospective cohort study was conducted using the MarketScan Hospital Drug Database (2015Q3-2017Q4). As infarct volume is not captured in the data, patients were included based on diagnosis codes for infarction of the middle cerebral artery or carotid artery, which are most closely associated with LHI. Within this group, cerebral edema was determined based on a diagnosis code of cerebral edema (ICD-10-CM G93.6) or herniation (G93.5), or a craniectomy procedure. Logistic regressions, comparing patients with edema vs. those without edema, were used to estimate the odds ratio of death, ICU admission, and tracheostomy/intubation during the hospital stay. Linear regression models were used to estimate the mean difference in length of hospital stay, length of ICU stay, and hospital charges. All models controlled for age, sex, and admission type.
Results:
A total of 11,772 patients were designated as likely LHI cases; 869 (7%) were identified with cerebral edema.
Table 1
compares inpatient outcomes and resource utilization in patients with vs. without cerebral edema. Patients with cerebral edema had significantly higher odds of death, ICU admission and tracheostomy/intubation. They also had longer hospital stays, longer stays in the ICU, and higher hospital charges.
Conclusion:
This study provides evidence in a real-world setting, highlighting the substantial clinical and economic burden associated with cerebral edema among patients hospitalized with LHI. Given the unmet needs, management strategies and interventions focusing on reducing cerebral edema among patients with LHI are warranted.
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Abstract
INTRODUCTION Hyperpyrexia is a severely elevated core body temperature secondary to an elevated hypothalamic set thermo-regulatory threshold. Hyperthermia is an elevated core body temperature beyond the normal hypothalamic set thermo-regulatory threshold. Intracranial hypotension can present with a wide variety of symptoms ranging from orthostatic headache up to coma. We report a rare case of hyperpyrexia associated with intracranial hypotension. METHODS A case report of a 55-year-old female patient with a history of angiogram-negative subarachnoid hemorrhage status post-ventriculoperitoneal (VP) shunt placement six years prior to admission who suddenly developed encephalopathy and high fever. Conventional management of the fever was unsuccessful. RESULTS AND MANAGEMENT Brain magnetic resonance imaging revealed signs of significant intracranial hypotension. When the VP shunt was tapped, no cerebrospinal fluid (CSF) could be obtained. Once the VP shunt settings were adjusted, the patient's encephalopathy and hyperpyrexia resolved. CONCLUSION Hyperpyrexia might be a presenting symptom of intracranial hypotension, likely, secondary to hypothalamic dysfunction and compression. In our case, hyperpyrexia was reversible as the intracranial hypotension was emergently treated. Spontaneous intracranial hypotension might be difficult to diagnose, especially if it presented with non-classical symptoms like fever; thus, physicians should be aware of such association.
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Affiliation(s)
- Omar Hussein
- Cerebrovascular and Neurocritical Care Division, Department of Neurology, Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 7th Floor, Columbus, OH, 43210, USA.
| | - Michel Torbey
- Cerebrovascular and Neurocritical Care Division, Department of Neurology, Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 7th Floor, Columbus, OH, 43210, USA
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15
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Abstract
PURPOSE OF REVIEW Weakness is a common reason patients are seen in neurologic consultation. This article reviews the differential diagnosis of neuromuscular disorders in the intensive care unit (ICU), discusses the intensive care needs and evaluation of respiratory failure in patients with neuromuscular disorders, and provides a practical guide for management. RECENT FINDINGS Although primary neuromuscular disorders used to be the most common cause for weakness from peripheral nervous system disease in the ICU, a shift toward ICU-acquired weakness is observed in today's clinical practice. Therefore, determining the cause of weakness is important and may have significant prognostic implications. Guillain-Barré syndrome and myasthenia gravis remain the most common primary neuromuscular disorders in the ICU. In patients with myasthenia gravis, it is important to be vigilant with the airway and institute noninvasive ventilation early in the course of the disease to attempt to avoid the need for intubation. On the other hand, patients with Guillain-Barré syndrome should be intubated without delay if the airway is at risk to avoid further complications. In patients with ICU-acquired weakness, failure to wean from the ventilator is usually the challenge. Early mobility, glucose control, minimizing sedation, and avoiding neuromuscular blocking agents remain the only therapeutic regimen available for ICU-acquired weakness. SUMMARY Critical care management of neuromuscular disorders requires a multidisciplinary approach engaging members of the ICU and consultative teams. Developing an airway management protocol could have implications on outcome and length of stay for patients with neuromuscular disorders in the ICU. Tending to the appropriate nuances of each patient who is critically ill with a neuromuscular disorder through evidence-based medicine can also have implications on length of stay and outcome.
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Powers CJ, Dornbos D, Mlynash M, Gulati D, Torbey M, Nimjee SM, Lansberg MG, Albers GW, Marks MP. Thrombectomy with Conscious Sedation Compared with General Anesthesia: A DEFUSE 3 Analysis. AJNR Am J Neuroradiol 2019; 40:1001-1005. [PMID: 31072970 DOI: 10.3174/ajnr.a6059] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE The optimal patient sedation during mechanical thrombectomy for ischemic stroke in the extended time window is unknown. The purpose of this study was to assess the impact of patient sedation on outcome in patients undergoing thrombectomy 6-16 hours from stroke onset. MATERIALS AND METHODS Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE 3) was a multicenter, randomized, open-label trial of thrombectomy for ICA and M1 occlusions in patients 6-16 hours from stroke onset. Subjects underwent thrombectomy with either general anesthesia or conscious sedation at the discretion of the treating institution. RESULTS Of the 92 patients who were randomized to intervention, 26 (28%) underwent thrombectomy with general anesthesia and 66 (72%) underwent thrombectomy with conscious sedation. Baseline clinical and imaging characteristics were similar among all groups. Functional independence at 90 days was 23% for general anesthesia, 53% for conscious sedation, and 17% for medical management (P = .009 for general anesthesia versus conscious sedation). Conscious sedation was associated with a shorter time from arrival in the angiosuite to femoral puncture (median, 14 versus 18 minutes; P = 0.05) and a shorter time from femoral puncture to reperfusion (median, 36 versus 48 minutes; P = .004). Sixty-six patients were treated at sites that exclusively used general anesthesia (n = 14) or conscious sedation (n = 52). For these patients, functional independence at 90 days was significantly higher in the conscious sedation subgroup (58%) compared with the general anesthesia subgroup (21%) (P = .03). CONCLUSIONS Patients who underwent thrombectomy with conscious sedation in the extended time window experienced a higher likelihood of functional independence at 90 days, a lower NIHSS score at 24 hours, and a shorter time from femoral puncture to reperfusion compared with those who had general anesthesia. This effect remained robust in institutions that only treated patients with a single anesthesia technique.
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Affiliation(s)
- C J Powers
- From the Departments of Neurological Surgery (C.J.P., D.D., S.M.N.)
| | - D Dornbos
- From the Departments of Neurological Surgery (C.J.P., D.D., S.M.N.)
| | - M Mlynash
- Departments of Neurology and Neurological Science (M.M., M.G.L., G.W.A.)
| | - D Gulati
- Neurology (D.G.), Ohio State University Wexner Medical Center, Columbus, Ohio
| | - M Torbey
- Department of Neurology (M.T.), University of New Mexico, Albuquerque, New Mexico
| | - S M Nimjee
- From the Departments of Neurological Surgery (C.J.P., D.D., S.M.N.)
| | - M G Lansberg
- Departments of Neurology and Neurological Science (M.M., M.G.L., G.W.A.)
| | - G W Albers
- Departments of Neurology and Neurological Science (M.M., M.G.L., G.W.A.)
| | - M P Marks
- Diagnostic Radiology (M.P.M.), Stanford University School of Medicine, Stanford, California
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17
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Lee VH, Powers CJ, Nimjee SM, Youssef P, Torbey M. Abstract WP109: Early Neurological Decline in Acute Ischemic Stroke Patients Receiving Thrombolysis With Large Vessel Occlusion and Initial Mild Deficits. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp109] [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:
One quarter of ischemic stroke patients with initial mild deficits will have poor outcome. We sought to determine the rate of early neurological decline in acute ischemic stroke patients with large vessel occlusion (LVO) presenting with mild deficits.
Methods:
Among 322 acute ischemic stroke patients who received intravenous tissue plasminogen activator (IVtPA) from July 1, 2016 to July 1, 2017, we identified 76 (23.6%) with imaging confirmed anterior circulation LVO, defined as M1, M2, or carotid terminus (ICAT). Basilar artery occlusions were excluded. Mild deficits were defined as National Institutes of Health Stroke Scale (NIHSS)
<
7. Data was abstracted on demographics, neuroimaging, need for intra-arterial therapy (IAT) revascularization, final Thrombolysis in Cerebral Infarction score (TICI), and clinical presentation. Early neurological decline was defined as NIHSS worsening of
>
4 points within 24 hours.
Results:
Among 76 patients with LVO, we identified 22 (29%) who presented with initial low NIHSS (< 7). The mean age was 64.7 years (range 26 to 93). IVtPA time from last known well (LKN) was a mean 2.7 hours (range 1.3 to 4.9). Most patients (91%) were transfers from outside facilities. LVO sites were as follows: 4 (18%) ICAT, 7 (32%) M1, and 11 (50%) M2. Most (19/22 86%) had CT perfusion imaging, and large mismatch was seen in 6/8 with worsening and 6/11 without worsening. Among the 22 patients with mild deficits initially, 9 (41%) had early neurological decline. Patients with early neurological decline were significantly older (77.8 vs 55.7 years, p=0.0008). Among 9 patients with decline, the mean change in NIHSS was 9 points (range, 4 to 18) and 3 (13.6%) underwent rescue therapy with IAT with TICI 2b (1) and TICI 3 (2) revascularization. On hospital discharge, LVO patients with neurological decline were significantly less likely to be discharged home compared with patients without decline (22% vs 69%, p=0.03).
Conclusions:
Among LVO patients who received IVtPA, 29% presented with mild deficits (NIHSS <7). Among these patients with mild deficits, early neurological decline occurred in 41% despite receiving IVtPA and was associated with older age. CTP mismatch did not accurately predict which patients would worsen.
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Affiliation(s)
- Vivien H Lee
- Neurology, The Ohio State Univ Wexner Med Cntr, Columbus, OH
| | - Ciarán J Powers
- Neurosurgery, The Ohio State Univ Wexner Med Cntr, Columbus, OH
| | - Shahid M Nimjee
- Neurosurgery, The Ohio State Univ Wexner Med Cntr, Columbus, OH
| | - Patrick Youssef
- Neurosurgery, The Ohio State Univ Wexner Med Cntr, Columbus, OH
| | - Michel Torbey
- Neurology, The Ohio State Univ Wexner Med Cntr, Columbus, OH
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18
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Dornbos DL, Powers CJ, Mlynash M, Gulati D, Torbey M, Nimjee SM, Lansberg MG, Marks MP. Abstract 152: Thrombectomy With Conscious Sedation Increases Functional Independence Compared to General Anesthesia: A DEFUSE-3 Post-hoc Analysis. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.152] [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:
The optimal method of patient sedation for mechanical thrombectomy in large vessel occlusion, particularly in the delayed time window, remains unknown. We evaluated the endovascular arm patients of the DEFUSE-3 trial for outcome differences between general anesthesia (GA) and conscious sedation (CS). While CS was the suggested method in the trial, the choice was ultimately left to the discretion of the treating interventionalist.
Methods:
A post-hoc analysis of patients enrolled in the DEFUSE-3 study was performed to assess differences in functional independence (modified Rankin scale of 0-2) at 90 days comparing patients undergoing GA to CS. The groups were also compared for baseline clinical and imaging characteristics and procedural process measures. Statistical analyses were performed using the Mann-Whitney U test, χ
2
-test, and logistic regression analysis.
Results:
Among patients undergoing thrombectomy, 26 (28%) utilized GA, while 66 (72%) underwent CS. Baseline demographics, clinical and radiologic characteristics were similar between the groups. Functional independence at 90 days (Figure 1) was observed in 53% of patients undergoing CS, compared to 23% of those receiving GA (adjusted-odds ratio of 0.27 (0.08-0.93), p=0.037). Patients undergoing CS had better NIHSS scores at 24 hours compared to GA (8 versus 15.5, p=0.032), but not at discharge (4 v 8, p=0.133). Importantly, CS yielded a faster time from arrival in the angiography suite to femoral puncture (median 14 minutes, interquartile range (IQR) 9-18) compared to GA (18 min, IQR 12-22, p=0.0497). Time from femoral puncture to reperfusion was also shorter with CS (median 36 min, IQR 25-51) than with GA (48 min, IQR 32-83, p=0.004).
Conclusions:
Patients undergoing thrombectomy between 6 to 16 hours following stroke onset exhibit improved functional independence at 90 days when treated with CS as compared to GA. This difference may be mediated by faster time to reperfusion in this cohort.
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Affiliation(s)
- David L Dornbos
- Dept of Neurological Surgery, The Ohio State Univ, Columbus, OH
| | - Ciaran J Powers
- Dept of Neurological Surgery, The Ohio State Univ, Columbus, OH
| | - Michael Mlynash
- Dept of Neurology and Neurological Science, Stanford Univ Sch of Medicine, Stanford, CA
| | - Deepak Gulati
- Dept of Neurology, The Ohio State Univ, Columbus, OH
| | - Michel Torbey
- Dept of Neurology, The Ohio State Univ, Columbus, OH
| | - Shahid M Nimjee
- Dept of Neurological Surgery, The Ohio State Univ, Columbus, OH
| | - Maarten G Lansberg
- Dept of Neurology and Neurological Science, Stanford Univ Sch of Medicine, Stanford, CA
| | - Michael P Marks
- Dept of Diagnostic Radiology, Stanford Univ Sch of Medicine, Stanford, CA
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19
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Yadav RS, Cash R, Wiles K, Lakhani SS, Torbey M, Lee VH. Abstract WP421: Intravenous Tissue Plasminogen Activator in Patients With Severe Hyperglycemia. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp421] [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:
Severe hyperglycemia (blood glucose > 500 mg/dL on presentation) is recognized to cause focal neurological deficits that can mimic acute stroke. We sought to describe patients with severe hyperglycemia who received intravenous tissue plasminogen activator (IVtPA) for possible acute ischemic stroke.
Methods:
With IRB approval, we retrospectively reviewed 579 patients who received IVtPA via telestroke from April 1, 2015 to October 1, 2017. Data was abstracted on demographics, neuroimaging, National Institutes of Health Stroke Scale (NIHSS), and clinical presentation. Hyperglycemia induced neurological deficits was defined as symptoms attributed to hyperglycemia without evidence of infarct on MRI brain diffusion weighted images (DWI)
Results:
Among 579 patients who received IVtPA, 8 (1.4%) presented with severe hyperglycemia. Among the patient with severe hyperglycemia, mean blood sugar level was 521 mg/dL. The mean IVtPA time administered was 3.1 hours (range, 2 to 4.3). In all 8 patients neurological symptoms lasted > 24 hours, and all had DWI performed. Four (50%) were diagnosed with ischemic stroke (DWI infarct) and 4 (50%) were diagnosed with hyperglycemia induced neurological deficits (DWI negative). Seven patients (87.5%) had CT brain perfusion imaging (CTP). All patients with ischemic stroke (3/3) had CTP defects, and 50% (2/4) of patients with hyperglycemia induced neurological deficits had CTP defects.
Conclusions:
Severe hyperglycemia on presentation among patients who receive IVtPA is not common (1.4%) and half of these were ultimately diagnosed with hyperglycemia induced neurological deficits. CTP showed focal perfusion defects in half of patients with hyperglycemia induced neurological deficits, suggesting this may be related to regional perfusion defects, possibly due to hyperglycemia induced microcirculatory changes. Further studies are warranted.
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20
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Lyden P, Pryor KE, Coffey CS, Cudkowicz M, Conwit R, Jadhav A, Sawyer RN, Claassen J, Adeoye O, Song S, Hannon P, Rost NS, Hinduja A, Torbey M, Lee JM, Benesch C, Rippee M, Rymer M, Froehler MT, Haley EC, Johnson M, Yankey J, Magee K, Qidwai J, Levy H, Haacke EM, Fawaz M, Davis TP, Toga AW, Griffin JH, Zlokovic BV. Final Results of the RHAPSODY Trial: A Multi-Center, Phase 2 Trial Using a Continual Reassessment Method to Determine the Safety and Tolerability of 3K3A-APC, A Recombinant Variant of Human Activated Protein C, in Combination with Tissue Plasminogen Activator, Mechanical Thrombectomy or both in Moderate to Severe Acute Ischemic Stroke. Ann Neurol 2019; 85:125-136. [PMID: 30450637 PMCID: PMC6342508 DOI: 10.1002/ana.25383] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Agonism of protease-activated receptor (PAR) 1 by activated protein C (APC) provides neuro- and vasculoprotection in experimental neuroinjury models. The pleiotropic PAR1 agonist, 3K3A-APC, reduces neurological injury and promotes vascular integrity; 3K3A-APC proved safe in human volunteers. We performed a randomized, controlled, blinded trial to determine the maximally tolerated dose (MTD) of 3K3A-APC in ischemic stroke patients. METHODS The NeuroNEXT trial, RHAPSODY, used a novel continual reassessment method to determine the MTD using tiers of 120, 240, 360, and 540 μg/kg of 3K3A-APC. After intravenous tissue plasminogen activator, intra-arterial mechanical thrombectomy, or both, patients were randomized to 1 of the 4 doses or placebo. Vasculoprotection was assessed as microbleed and intracranial hemorrhage (ICH) rates. RESULTS Between January 2015 and July 2017, we treated 110 patients. Demographics resembled a typical stroke population. The MTD was the highest-dose 3K3A-APC tested, 540 μg/kg, with an estimated toxicity rate of 7%. There was no difference in prespecified ICH rates. In exploratory analyses, 3K3A-APC reduced ICH rates compared to placebo from 86.5% to 67.4% in the combined treatment arms (p = 0.046) and total hemorrhage volume from an average of 2.1 ± 5.8 ml in placebo to 0.8 ± 2.1 ml in the combined treatment arms (p = 0.066). INTERPRETATION RHAPSODY is the first trial of a neuroprotectant for acute ischemic stroke in a trial design allowing thrombectomy, thrombolysis, or both. The MTD was 540 μg/kg for the PAR1 active cytoprotectant, 3K3A-APC. A trend toward lower hemorrhage rate in an exploratory analysis requires confirmation. CLINICAL TRIAL REGISTRATION Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT02222714. ANN NEUROL 2019;85:125-136.
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Affiliation(s)
| | | | | | - Merit Cudkowicz
- Massachusetts General Hospital, Neurological Clinical Research Institute, Boston
| | - Robin Conwit
- National Institutes of Health, National Institute of Neurological Disorders and Stroke
| | | | | | - Jan Claassen
- Neurological Institute, Columbia University, New York, NY
| | - Opeolu Adeoye
- Department of Emergency Medicine, University of Cincinnati, Cincinnati
| | - Shlee Song
- Cedars-Sinai Medical Center, Los Angeles
| | | | - Natalia S. Rost
- Massachusetts General Hospital, Neurological Clinical Research Institute, Boston
| | | | - Michel Torbey
- Ohio State University Medical Center, Columbus, Ohio
| | | | | | | | | | | | | | - Mark Johnson
- University of Texas, Southwestern Medical Center, Dallas
| | | | | | | | | | | | | | - Thomas P. Davis
- Department of Medical Pharmacology, College of Medicine, University of Arizona, Tucson, AZ
| | - Arthur W. Toga
- Laboratory of Neuro Imaging, Institute of Neuroimaging and Informatics, Keck School of Medicine, University of Southern California Los Angeles
| | | | - Berislav V. Zlokovic
- Zilkha Neurogenic Institute and Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California Los Angeles
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21
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Affiliation(s)
- Edward M Manno
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH; Departments of Neurosurgery, Neurology, and Critical Care, Mayo Clinic, Jacksonville, FL; Rush University College of Nursing, Chicago, IL; Departments of Neurology, Anesthesiology-Critical Care Medicine, Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; The Ohio State University Wexner Medical Center, Cerebrovascular and Neurocritical Care Division, Department of Neurology and Neurosurgery, Columbus, OH; Departments of Anesthesia/Critical Care Medicine, and Neurosurgery, Johns Hopkins University, Baltimore, MD; Department of Neurology, University of California San Francisco, San Francisco, CA
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22
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Gulati D, Nasir M, Dua D, Torbey M. Abstract TP220: Is Fibrinogen a Reliable Lab to Follow in Acute Ischemic Stoke After Thrombolysis. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.tp220] [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
Background:
American Heart Association suggests empirical therapies (cryoprecipitate, FFP and platelets) for post-IVtpa hemorrhage but acknowledges the lack of evidence to support any specific therapy. Different institutions have developed care pathways for post-IVtpa sICH involving frequent fibrinogen level checks. During thrombolysis, circulating fibrinogen is decreased, and thus rapid administration of cryoprecipitate is recommended. A marker of fibrinogen of <100-150 mg/dL has been traditionally used as a cutoff to suggest effective thrombolysis or administration of cryoprecipitate or to assess the risk of bleeding complications. Monitoring of fibrinogen level has been used to guide the reversal therapy in the setting of post-IVtpa hemorrhage. This practice is not fully addressed in the literature.
Purpose:
To determine the significance of fibrinogen level in relation to thrombolysis in acute ischemic stroke (AIS) based on our single center experience.
Methods:
We retrospectively reviewed fibrinogen levels in two groups of patients with AIS who presented to our comprehensive stroke center. First group included 50 patients who received IVtpa including two patients w/ post-IVtpa sICH and second group included 50 patients with AIS who could not receive IVtpa due to contraindication. Fibrinogen level was checked in immediate post-IVtpa period usually within 2hr of IVtpa or 6hr from onset.
Results:
The mean fibrinogen level in first group with patients with AIS who received IVtpa is 321.65 mg/dl with range from 102 to 533 mg/dl. Normal reference range is 220-410mg/dl. The mean fibrinogen level in second group without IVtpa is 376mg/dl with range from 124 to 583mg/dl. The fibrinogen level in two patients with post-IVtpa sICH was 216 and 282 mg/dl.
Conclusions:
No significant correlation is found between fibrinogen level (<100mg/dl) and IVtpa use. We also found no significant change in fibrinogen level in patients with post-IVtpa sICH even though there are only two cases included so far. Above finding suggests that we should focus our research on mechanism other than decrease fibrinogen level to be an underlying cause of post-IVtpa hemorrhage in order to develop agent for better reversal and to prevent continued hematoma expansion.
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Affiliation(s)
| | | | - Dharti Dua
- Neurology, Ohio State Univ, Columbus, OH
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23
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Torbey M. Brain injury and the lung. Journal of Neuroanaesthesiology and Critical Care 2016. [DOI: 10.4103/2348-0548.174729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Michel Torbey
- Department of Neurology and Neurosurgery, Wexner Medical Centre, Ohio State University, Ohio, USA
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24
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Hinduja A, Limaye K, Ravilla R, Sasapu A, Papanikolaou X, Wei L, Torbey M, Waheed S. Spectrum of Cerebrovascular Disease in Patients with Multiple Myeloma Undergoing Chemotherapy-Results of a Case Control Study. PLoS One 2016; 11:e0166627. [PMID: 27902730 PMCID: PMC5130211 DOI: 10.1371/journal.pone.0166627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/01/2016] [Indexed: 12/21/2022] Open
Abstract
Objectives Patients with multiple myeloma (MM) are at increased risk of arterial thrombosis. Our aim was to determine the risk factors, mechanisms and outcome of strokes in these patients. Methods We conducted a retrospective matched case–control study from our database of MM patients enrolled in Total Therapy (TT) 2, TT3a and TT3b protocols who developed a vascular event (transient ischemic attack, ischemic stroke, or intracerebral hemorrhage) from October 1998 to January 2014. Cases were matched for age-matched selected controls. Baseline demographics, risk factors, MM characteristics, laboratory values, and mortality of cases were compared to those of controls. Multivariate logistic regression analysis identified risk factors associated with stroke. Ischemic strokes (IS) were classified with modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Results Of 1,148 patients, 46 developed a vascular event (ischemic stroke, 33; transient ischemic attack, 11; hypertensive intracerebral hemorrhage, 2). Multivariate logistic regression analysis determined renal insufficiency (odds Ratio, 3.528; 95% CI, 1.36–9.14; P = 0.0094) and MM Stages I and II (odds Ratio, 2.770, 95% CI, 1.31–5.81; p = 0.0073) were independent predictors of stroke. In our study, strokes attributable to hypercoagulability, atrial fibrillation and small-vessel occlusion were common mechanisms. After a stroke, 78% of patients were discharged to home or a rehabilitation facility and 4% to a long-term nursing facility; in-hospital mortality was 15%. Despite suffering a stroke no significant differences in survival were observed. Conclusion In our cohort of multiple myeloma patients, renal failure and MM Stages I and II had increased risk of stroke.
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Affiliation(s)
- Archana Hinduja
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
- * E-mail:
| | - Kaustubh Limaye
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Rahul Ravilla
- Department of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Appalnaidu Sasapu
- Department of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Xenofon Papanikolaou
- Multiple Myeloma for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Lai Wei
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Michel Torbey
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
- Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Sarah Waheed
- Multiple Myeloma for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
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25
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Zhu Y, Liu F, Zou X, Torbey M. Comparison of unbiased estimation of neuronal number in the rat hippocampus with different staining methods. J Neurosci Methods 2015; 254:73-9. [PMID: 26238727 DOI: 10.1016/j.jneumeth.2015.07.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [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: 02/06/2015] [Revised: 07/20/2015] [Accepted: 07/23/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND NeuN and Nissl staining (toluidine blue, cresyl violet staining) are routinely used methods in unbiased stereological estimation of the total number of hippocampal neurons. NEW METHOD In the present study, we stained serial frozen coronal sections from 5 normal adult male Sprague-Dawley rat brains with different methods, measured the deformation of hippocampal area in brain sections and estimated the total number of hippocampal neurons using the optical fractionator. RESULTS The deformation in x, y-axis was not obviously different with different staining protocols, but shrinkage in z-axis was significant after staining (p < 0.001). NeuN staining produced significant higher estimate number than cresyl violet staining by 24% (p = 0.002), however, NeuN and Cresyl Violet staining showed a high degree of correlation in quantification of total neuronal numbers and both methods are suitable for unbiased stereological estimation. COMPARISON WITH EXISTING METHOD (S) NeuN is more reliable but if time is limited or the number of animals used in experiments is high, cresyl violet staining may be a feasible method. CONCLUSIONS Compared with previous estimates of the neurons number in rat hippocampus, our present data is reliable and the stereological analysis based on our system is a cost-effective unbiased method for estimation of neuron number.
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Affiliation(s)
- Yongjin Zhu
- Department of Neurology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Fuxin Liu
- Department of Neurology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Xunchang Zou
- Department of Neurology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Michel Torbey
- Department of Neurology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States; Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, United States.
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26
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Castellon Larios K, Rybka K, Greene-Chandos D, Bergese S, Torbey M. Abstract W P240: The Effect of Telestroke Network on Tissue Plasminogen Activator Utilization and Door to Needle Time on Rural Hospitals. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.wp240] [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:
Stroke is the 4
th
leading cause of death in the United States. Only 2-3% of ischemic stroke patients are receiving Tissue plasminogen activator (t-PA) despite an increase in time window to 4.5 hours. With less than 85% of the US population living within 30 minutes of primary stroke centers, it is important to review the effectiveness of telestroke network in delivering t-PA. The Ohio State University Wexner Medical Center (OSUWMC) Telestroke network was established in May 2011. Currently the network expands across 24 spokes located in rural central Ohio. Most of these centers have not given t-PA prior to joining the network.
Objective:
Evaluate the effectiveness of the OSUWMC telestroke in delivering t-PA for acute ischemic stroke in a rural setting and compare the stroke quality metrics to Ohio Coverdell registered Hospitals.
Methods:
We conducted a retrospective data review from the OSUWMC Telestroke Network database from May 22, 2011 to November 30, 2012. This included demographics, diagnostic impression, NIHSS score, average symptom onset to ED arrival, average door to CT time, average consult duration. t-PA administration and transfer status to OSUMWC were also collected. Summary statistics were generated using Microsoft Excel (version 2010, Microsoft Corporation) and SAS (version 9.3, SAS Institute).
Results:
In this study, a total of 422 Telestroke consultations were completed. 180 patients were diagnosed with ischemic stroke (57.5%). Average NIHSS score was 5 ±6, average symptom onset to ED arrival time was 4 hours 26 minutes (n=378), and the average door to CT time was 26 minutes (n=204). Forty-four percent (n=80) were approved to receive IV t-PA; 60% within one hour of ED arrival. From this number of patients thirty percent received t-PA within one hour compared to 38% in Ohio Coverdell hospitals.
Conclusion:
The implementation of telestroke network can deliver care that is equivalent to primary stroke centers. This approach may be an effective tool for rapid evaluation of patients in remote hospitals that require neurologic specialists.
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27
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Quirk BJ, Torbey M, Buchmann E, Verma S, Whelan HT. Near-infrared photobiomodulation in an animal model of traumatic brain injury: improvements at the behavioral and biochemical levels. Photomed Laser Surg 2012; 30:523-9. [PMID: 22793787 DOI: 10.1089/pho.2012.3261] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The purpose of this was to evaluate the neuroprotective effects of near-infrared (NIR) light using an in-vivo rodent model of traumatic brain injury (TBI), controlled cortical impact (CCI), and to characterize changes at the behavioral and biochemical levels. BACKGROUND DATA NIR upregulates mitochondrial function, and decreases oxidative stress. Mitochondrial oxidative stress and apoptosis are important in TBI. NIR enhanced cell viability and mitochondrial function in previous in-vitro TBI models, supporting potential NIR in-vivo benefits. METHODS Sprague-Dawley rats were divided into three groups: severe TBI, sham surgery, and anesthetization only (behavioral response only). Cohorts in each group were administered either no NIR or NIR. They received two 670 nm LED treatments (5 min, 50 mW/cm(2), 15 J/cm(2)) per day for 72 h (chemical analysis) or 10 days (behavioral). During the recovery period, animals were tested for locomotor and behavioral activities using a TruScan device. Frozen brain tissue was obtained at 72 h and evaluated for apoptotic markers and reduced glutathione (GSH) levels. RESULTS Significant differences were seen in the TBI plus and minus NIR (TBI+/-) and sham plus and minus NIR (S+/-) comparisons for some of the TruScan nose poke parameters. A statistically significant decrease was found in the Bax pro-apoptotic marker attributable to NIR exposure, along with lesser increases in Bcl-2 anti-apoptotic marker and GSH levels. CONCLUSIONS These results show statistically significant, preclinical outcomes that support the use of NIR treatment after TBI in effecting changes at the behavioral, cellular, and chemical levels.
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Affiliation(s)
- Brendan J Quirk
- Department of Neurology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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28
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Mutgi S, Greene-Chandos D, Torbey M, Behrouz R. Tuberculous Meningitis in a Healthy Young Woman: Case Report and Review of Literature (P03.250). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p03.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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29
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Selim M, Yeatts S, Goldstein JN, Gomes J, Greenberg S, Morgenstern LB, Schlaug G, Torbey M, Waldman B, Xi G, Palesch Y. Safety and tolerability of deferoxamine mesylate in patients with acute intracerebral hemorrhage. Stroke 2011; 42:3067-74. [PMID: 21868742 DOI: 10.1161/strokeaha.111.617589] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Treatment with the iron chelator, deferoxamine mesylate (DFO), improves neurological recovery in animal models of intracerebral hemorrhage (ICH). We aimed to evaluate the feasibility, safety, and tolerability of varying dose-tiers of DFO in patients with spontaneous ICH, and to determine the maximum tolerated dose to be adopted in future efficacy studies. METHODS This was a multicenter, phase-I, dose-finding study using the Continual Reassessment Method. DFO was administered by intravenous infusion for 3 consecutive days, starting within 18 hours of ICH onset. Subjects underwent repeated clinical assessments through 90 days, and computed tomography neuroimaging pre- and post-drug-administration. RESULTS Twenty subjects were enrolled onto 5 dose tiers, starting with 7 mg/kg per day and ending with 62 mg/kg per day as the maximum tolerated dose. Median age was 68 years (range, 50-90); 60% were men; and median Glasgow Coma Scale and National Institutes of Health Stroke Scale scores on admission were 15 (5-15) and 9 (0-39), respectively. ICH location was lobar in 40%, deep in 50%, and brain stem in 10%; intraventricular hemorrhage was present in 15%. DFO was discontinued because of adverse events in 2 subjects (10%). Six subjects (30%) experienced 12 serious adverse events, none of which were drug-related. DFO infusions were associated with mild blood-pressure-lowering effects. Fifty percent of patients had modified Rankin scale scores ≤2, and 39% had modified Rankin scale scores of 4 to 6 on day 90; 15% died. CONCLUSIONS Consecutive daily infusions of DFO after ICH are feasible, well-tolerated, and not associated with excessive serious adverse events or mortality. Our findings lay the groundwork for future studies to evaluate the efficacy of DFO in ICH.
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Affiliation(s)
- Magdy Selim
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Stroke Division, 330 Brookline Avenue-Palmer 127, Boston, MA 02215, USA.
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Abou-Chebl A, Sung G, Barbut D, Torbey M. Local brain temperature reduction through intranasal cooling with the RhinoChill device: preliminary safety data in brain-injured patients. Stroke 2011; 42:2164-9. [PMID: 21680904 DOI: 10.1161/strokeaha.110.613000] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [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
BACKGROUND AND PURPOSE Hypothermia is neuroprotectant but currently available cooling methods are laborious, invasive, and require whole-body cooling. There is a need for less invasive cooling of the brain. This study was conducted to assess the safety and efficacy of temperature reduction of the RhinoChill transnasal cooling device. METHODS We conducted a prospective single-arm safety and feasibility study of intubated patients for whom temperature reduction was indicated. After rhinoscopy, the device was activated for 1 hour. Brain, tympanic, and core temperatures along with vital signs and laboratory studies were recorded. All general and device-related adverse events were collected for the entire hypothermia treatment. RESULTS A total of 15 patients (mean age, 50.3 ± 17.1 years) were enrolled. Brain injury was caused by intracerebral hemorrhage, trauma, and ischemic stroke in equal numbers. Hypothermia was induced for fever control in 9 patients and for neuroprotection/intracranial pressure control in 6. Core temperature, brain temperature, and tympanic temperature were reduced an average of 1.1 ± 0.6°C (range, 0.3 to 2.1°C), 1.4 ± 0.4°C (range, 0.8 to 5.1°C), and 2.2 ± 2°C (range, 0.5 to 6.5°C), respectively. Only 2 patients did not achieve the goal of ≥1°C decrease in temperature. Brain temperature, tympanic temperature, and core temperature reductions were similar between the afebrile and febrile patients. There were no unanticipated adverse events and only 1 anticipated adverse event: hypertension in 1 subject that led to discontinuation of cooling after 30 minutes. There were no nasal complications. CONCLUSIONS Intranasal cooling with the RhinoChill device appears safe and effectively lowers brain and core temperatures. Further study is warranted to assess the efficacy of hypothermia through intranasal cooling for brain-injured patients.
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Affiliation(s)
- Alex Abou-Chebl
- Department of Neurology, University of Louisville School of Medicine, Louisville, KY 40202, USA.
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Yang ZJ, Torbey M, Li X, Bernardy J, Golden WC, Martin LJ, Koehler RC. Dopamine receptor modulation of hypoxic-ischemic neuronal injury in striatum of newborn piglets. J Cereb Blood Flow Metab 2007; 27:1339-51. [PMID: 17213860 PMCID: PMC2084487 DOI: 10.1038/sj.jcbfm.9600440] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Dopamine receptors regulate glutamatergic neurotransmission and Na(+),K(+)-ATPase via protein kinase A (PKA) and dopamine- and cAMP-regulated phosphoprotein of 32 kDa (DARPP-32)-dependent signaling. Consequently, dopamine receptor activation may modulate neonatal hypoxic-ischemic (H-I) neuronal damage in the selectively vulnerable putamen enriched with dopaminergic receptors. Piglets subjected to two durations of hypoxia followed by asphyxic cardiac arrest were treated with a D1-like (SCH23390) or D2-like (sulpiride) receptor antagonist. At 4 days of recovery from less severe H-I, the remaining viable neurons in putamen were 60% of control, but nearly completely salvaged by pretreatment with SCH23390 or sulpiride. After more severe H-I in which only 18% of neurons were viable, partial neuroprotection was seen with SCH23390 pretreatment (50%) and posttreatment (39%) and with sulpiride pretreatment (35%), but not with sulpiride posttreatment (24%). Dopamine was significantly elevated in microdialysis samples from putamen during asphyxia and the first 15 mins of reoxygenation. Pretreatment with SCH23390 or sulpiride largely attenuated the increased nitrotyrosine and the decreased Na(+),K(+)-ATPase activity that occurred at 3 h after severe H-I. Pretreatment with SCH23390, but not sulpiride, also attenuated H-I-induced increases in PKA-dependent phosphorylation of Thr34 on DARPP-32, Ser943 on the alpha subunit of Na(+),K(+)-ATPase, and Ser897 of the N-methyl-D-aspartate (NMDA) receptor NR1 subunit. These findings indicate that D1 and D2 dopamine receptor activation contribute to neuronal death in newborn putamen after H-I in association with increased protein nitration and decreased Na(+),K(+)-ATPase activity. Furthermore, mechanisms of D1 receptor toxicity may involve DARPP-32-dependent phosphorylation of NMDA receptor NR1 and Na(+),K(+)-ATPase.
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Affiliation(s)
- Zeng-Jin Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Luft AR, Buitrago MM, Torbey M, Bhardwaj A, Razumovsky A. Biphasic cerebral blood flow velocity profile in patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2005; 1:455-9. [PMID: 16174949 DOI: 10.1385/ncc:1:4:455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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: 11/11/2022]
Abstract
INTRODUCTION Increases in cerebral blood flow velocity (CBFV) as measured by transcranial Doppler (TCD) sonography are reflective of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). In serial TCD measurements, some patients exhibit CBFV temporal profiles with two peaks (biphasic). The significance of this finding remains unclear. This retrospective case-control study was conducted to investigate the characteristics and possible predictors of biphasic CBFV profiles. METHODS Biphasic CBFV profiles were identified in serial TCD examinations (every 1-2 days) of 182 consecutive patients admitted for aneurysmal SAH based on CBFV profiles of the middle cerebral artery on the side of higher maximum velocity. Patients undergoing angioplasty were excluded. Patients meeting these criteria (study patients) were compared to control patients matched for age and Hunt and Hess grade. RESULTS Eighteen patients (9.9%) demonstrated biphasic CBFV profiles. The first CBFV (134 +/- 11 cm/second) peak occurred on post-SAH day 6 +/- 1, and the second peak (148 +/- 12 cm/second) on day 13 +/- 1. Study patients more often exhibited focal (p < 0.05) symptoms at the time of the first peak. No patient deteriorated neurologically at the time of the second peak. No correlation was observed between CBVF and mean arterial pressure or central venous pressure trends. CONCLUSION Serial TCD assessment identifies patients with SAH and a biphasic CBFV temporal profile. Although the second peak usually is not associated with a worsening of symptoms, these patients were more likely to exhibit clinical symptoms during the first CBFV peak.
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Affiliation(s)
- Andreas R Luft
- Division of Neurosciences Critical Care, Johns Hopkins University, Baltimore, MD, USA.
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Varelas PN, Rickert KL, Cusick J, Hacein-Bey L, Sinson G, Torbey M, Spanaki M, Gennarelli TA. Intraventricular Hemorrhage after Aneurysmal Subarachnoid Hemorrhage: Pilot Study of Treatment with Intraventricular Tissue Plasminogen Activator. Neurosurgery 2005; 56:205-13; discussion 205-13. [PMID: 15670368 DOI: 10.1227/01.neu.0000147973.83688.d8] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2004] [Accepted: 10/06/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Intraventricular (IVen) hemorrhage is considered a predictor of poor outcome after subarachnoid hemorrhage (SAH). This prospective study examines the feasibility and outcome of administration of IVen tissue plasminogen activator (tPA) after aneurysmal SAH. METHODS Ten patients with SAH who received IVen tPA after the aneurysm had been secured were compared with 10 age-, sex-, and Glasgow Coma Scale score-matched control patients. The primary end point was third and fourth ventricle clot resolution. IVen blood was quantified by use of the Graeb and Le Roux scales on admission and at an additional time (equal or longer for the control group) after the injection was terminated. RESULTS Six men and four women with a mean age of 52 years in each group were evaluated. On average, 3.5 mg tPA was injected 68 +/- 51 hours after admission without ensuing complications. Although the treated group had significantly more IVen blood on admission than control subjects (mean Le Roux scale +/- standard deviation, 11 +/- 3 versus 7.6 +/- 4.2, P = 0.055, and mean Graeb scale +/- standard deviation, 8.5 +/- 2.3 in tPA versus 5.3 +/- 3, P < 0.02), it also had a significant decrease in the amount of IVen blood (mean Le Roux and Graeb scale decrease +/- standard deviation, 6.7 +/- 3.3 and 4.8 +/- 2 in tPA patients versus 0.9 +/- 3.2 and 0.5 +/- 2.6 in control subjects, P = 0.002). The tPA group had a non-statistically significantly shorter length of stay, decreased mortality, and better Glasgow Outcome Scale and modified Rankin Scale scores at discharge. Treated survivors showed a decreased need for shunt placement (2 [22%] of 9 patients versus 5 [83%] of 6 control subjects, P = 0.04). CONCLUSION This pilot study shows that IVen tPA administration is feasible without complications after SAH and may be associated with better outcomes. These results warrant a randomized clinical trial.
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Affiliation(s)
- Panayiotis N Varelas
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Hillis AE, Ulatowski JA, Barker PB, Torbey M, Ziai W, Beauchamp NJ, Oh S, Wityk RJ. A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke. Cerebrovasc Dis 2003; 16:236-46. [PMID: 12865611 DOI: 10.1159/000071122] [Citation(s) in RCA: 159] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2002] [Accepted: 12/11/2002] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Small, unrandomized studies have indicated that pharmacologically induced blood pressure elevation may improve function in ischemic stroke, presumably by improving blood flow to ischemic, but noninfarcted tissue (which may be indicated by diffusion-perfusion mismatch on MRI). We conducted a pilot, randomized trial to evaluate effects of pharmacologically induced blood pressure elevation on function and perfusion in acute stroke. METHODS Consecutive series of patients with large diffusion-perfusion mismatch were randomly assigned to induced blood pressure elevation ('treated' patients, n = 9) or conventional management ('untreated' patients, n = 6). RESULTS There were no significant differences between groups at baseline. NIH Stroke Scale (NIHSS) scores were lower (better) in treated versus untreated patients at day 3 (mean 5.6 vs. 12.3; p = 0.01) and week 6-8 (mean 2.8 vs. 9.7; p < 0.04). Treated (but not untreated) patients showed significant improvement from day 1 to day 3 in NIHSS score (from mean 10.2 to 5.6; p < 0.002), cognitive score (from mean 58.7 to 27.9% errors; p < 0.002), and volume of hypoperfused tissue (mean 132 to 58 ml; p < 0.02). High Pearson correlations between the mean arterial pressure (MAP) and accuracy on daily cognitive tests indicated that functional changes were due to changes in MAP. CONCLUSION Results warrant a full-scale, double-blind clinical trial to evaluate the efficacy and risk of induced blood pressure elevation in selective patients with acute/subacute stroke.
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Affiliation(s)
- A E Hillis
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Md., USA.
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Fedder W, Golembiewski A, Conti M, Book D, Torbey M. Stroke prevention 2003: are we any closer to adequate blood pressure control? J Stroke Cerebrovasc Dis 2003. [DOI: 10.1016/j.jstrokecerebrovasdis.2003.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Abstract
The authors report an unusual case of a patient with low-pressure hydrocephalus and a ventriculopleural shunt, in whom routine respiratory management performed using positive-pressure ventilation caused shunt obstruction and coma. While the patient received positive-pressure ventilation with external cerebrospinal fluid (CSF) drainage at subatmospheric pressure, the ventricles returned to normal size and the coma rapidly reversed. After the authors' recognition of the effect of positive-pressure ventilation on intrapleural pressure and ventriculopleural shunt function, and the subsequent removal of positive-pressure ventilation, CSF flow through the shunt resumed and the patient's coma resolved.
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Affiliation(s)
- V L Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Affiliation(s)
- C E Henderson
- Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, New York
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