Successful Thrombectomy of the Posterior Cerebral Artery P2 Segment in a 61-Year-Old Man with Acute Ischaemic Stroke: A Case Report

BACKGROUND Acute ischemic stroke in the posterior cerebral artery (PCA) territory can lead to persistent disabling deficits. The PCA is divided into 4 segments. The P2 segment begins at the posterior communicating artery and curves around the midbrain and above the tentorium cerebelli. This report is of a 61-year-old man with acute ischemic stroke involving the left hippocampus treated with direct thrombectomy of the P2 segment of the PCA. CASE REPORT A 61-year-old white man presented with transient amnesia, aphasia, right-sided hemianopia, dizziness, and persistent acute memory deficits. Magnetic resonance imaging (MRI) showed a left hippocampal acute ischemic stroke with left PCA occlusion in the P2 segment. Despite a low National Institutes of Health Stroke Scale (NIHSS) score and the already-formed lesion in the hippocampus, successful stent retriever thrombectomy was performed due to a considerable perfusion-diffusion mismatch and a persistent potentially disabling neurocognitive deficit. Due to partial thrombus dislocation, occlusion of the common origin of the right posterior inferior cerebellar artery (PICA) and anterior inferior cerebellar artery (AICA) occurred and was immediately treated by thrombectomy to prevent severe cerebellar infarction. His clinical symptoms completely resolved and a neuropsychological exam showed no residual deficits. CONCLUSIONS Thrombectomy of the P2 segment of the PCA is feasible and can be considered to treat patients with acute occlusion at risk for persistent disabling deficits, based on clinical estimation of the impact of such deficits and the presence of potentially salvageable brain tissue. Potential procedural complications should be sought out and immediately treated, if technically feasible.

Relevance of National Institutes of Health Stroke Scale subitems for best revascularization therapy in minor stroke patients with large vessel occlusion: An observational multicentric study

BACKGROUND AND PURPOSE

The best management of acute ischemic stroke patients with a minor stroke and large vessel occlusion is still uncertain. Specific clinical and radiological data may help to select patients who would benefit from endovascular therapy (EVT). We aimed to evaluate the relevance of National Institutes of Health Stroke Scale (NIHSS) subitems for predicting the potential benefit of providing EVT after intravenous thrombolysis (IVT; "bridging treatment") versus IVT alone.

METHODS

We extracted demographic, clinical, risk factor, radiological, revascularization and outcome data of consecutive patients with M1 or proximal M2 middle cerebral artery occlusion and admission NIHSS scores of 0-5 points, treated with IVT ± EVT between May 2005 and March 2021, from nine prospectively constructed stroke registries at seven French and two Swiss comprehensive stroke centers. Adjusted interaction analyses were performed between admission NIHSS subitems and revascularization modality for two primary outcomes at 3 months: non-excellent functional outcome (modified Rankin Scale score 2-6) and difference in NIHSS score between 3 months and admission.

RESULTS

Of the 533 patients included (median age 68.2 years, 46% women, median admission NIHSS score 3), 136 (25.5%) initially received bridging therapy and 397 (74.5%) received IVT alone. Adjusted interaction analysis revealed that only facial palsy on admission was more frequently associated with excellent outcome in patients treated by IVT alone versus bridging therapy (odds ratio 0.47, 95% confidence interval 0.24-0.91; p = 0.013). Regarding NIHSS difference at 3 months, no single NIHSS subitem interacted with type of revascularization.

CONCLUSIONS

This retrospective multicenter analysis found that NIHSS subitems at admission had little value in predicting patients who might benefit from bridging therapy as opposed to IVT alone. Further research is needed to identify better markers for selecting EVT responders with minor strokes.

From damage control surgery to complex abdominal wall reconstruction It is possible even in the elderly in a Spoke Center?

AIM

To describe our Spoke Center experience in Damage Control Surgery (DCS) in a non traumatic patient and the possibility of delayed abdominal wall reconstruction (AWR). Material of Study The case of a 73 years old Caucasian male treated with DCS for a septic shock due to a duodenal perforation and his clinical course till the abdominal wall reconstruction.

RESULTS

We made DCS with abbreviated laparotomy, suture of the ulcer and duodenostomy with a foley placed in right hypochondrium. Patiens was discharged with a low-flow fistula and with TPN. After 18 months we made an open cholecystectomy and a complete abdominal wall reconstruction with Fasciotens Hernia System® adding a biological mesh.

DISCUSSION AND COMMENTS

Periodic training in emergency settings and in complex abdominal wall procedures is the right way to manage critic clinical case. Like Niebuhr's abbreviated laparotomy experience also in our case this procedure allows primary closure of complex hernias and is potentially less prone to complications than component separation methods. Unlike Fung's experience we didn' t use negative pressure wound therapy system (NPWT) equally achieving good results.

CONCLUSIONS

Elective repair of abdominal wall disaster is possible even in elderly patients who have been treated by abbreviated laparotomy and DCS surgery. In order to obtain good results is fundamental to have a trained staff.

KEY WORDS

Damage Control Surgery (DCS), Giant incisional Hernia, Abdominal Wall Repair.

Effect of the mode of delivery on the risk of endometriosis recurrence: a retrospective cohort study

OBJECTIVE

To evaluate the risk of endometriosis recurrence according to the mode of delivery (cesarean section vs. vaginal birth) in patients who had become pregnant with a live birth after surgery for endometriosis.

DESIGN

A retrospective cohort study. A Cox proportional-hazards regression was performed to evaluate the risk factors for endometriosis recurrence at 36 months of follow-up after the last pregnancy.

SETTING

Academic hospital.

PATIENT(S)

Patients who have had ≥1 pregnancy with a live birth following conservative surgery for ovarian endometriosis performed from January 2009 to December 2016 at our institution.

INTERVENTION(S)

Patients who underwent ≥1 cesarean section after surgery for endometriosis.

MAIN OUTCOME MEASURES

The recurrence rate of endometriosis after live-birth pregnancies obtained after the first surgery for endometriosis.

RESULTS

Patients with a history of ≥1 cesarean section after surgery for endometriosis have a higher risk of endometriosis recurrence than the patients who have had a vaginal birth, with an adjusted hazard ratio of 2.25 (95% confidence interval, 1.27-3.96).

CONCLUSION

A cesarean section after surgery for endometriosis is associated with a twofold high risk of endometriosis recurrence with respect to vaginal birth. A different follow-up approach may be needed in those patients, and avoiding inappropriate indications for cesarean sections in pregnant patients with a history of surgery for endometriosis is necessary.

Emergency Surgery in a "No-Covid-19 Spoke Center" during the pandemic. One year of experience and a new organizational model

AIM

We analysed our one-year surgical activity in a spoke 'COVID-19 free' centre during the pandemic in South Italy.

MATERIAL OF STUDY

From Feb 2020 to Feb 2021 we performed 800 operations (40% in emergency and 60% of major surgery). We applied restrictive measures for the access of patients in our department from 15/2/2020 after several cases of unclear fever. Visitors were not allowed to stay in the ward.

RESULTS

In the first period of lockdown, from March to June 2020, in our Region, biomolecular test was indicated only for symptomatic people. We organized the hospitalization with a sealed compartment system (that we defined "boing system") in which the patient stationed in an 'isolation room' for at least 48 hours upon the entry. From July 2020 molecular test were made to all patients before hospitalization. The boing system remains for emergency recovery.

DISCUSSION

In the first phase of pandemia we chose to subject patients to serological examination based on the IgM assay to consider them negative. We organized the hospitalization with a sealed compartment system (that we defined "boing system") CONCLUSION: In the first phase of the pandemic the serological examination has shown high specificity in identifying positive patients for COVID 19. In that period we supposed that patients with negative serology could be considered non-contagious Neither patients or staff has been resulted positive to SarS CoV2 test.

KEY WORDS

Covid 19, Emercency Surgery, Spoke Center, Pandemia, Serological Tests.

Predictors of Early Stroke or Death in Patients Undergoing Transcatheter Aortic Valve Implantation

BACKGROUND/OBJECTIVE

While postoperative stroke is a known complication of Transcatheter Aortic Valve Implantation (TAVI), predictors of early stroke occurrence have not been specifically reviewed. The objective of this study was to estimate the predictors and incidence of stroke during the first 30 days post-TAVI.

METHODS

A cohort of 506 consecutive patients having undergone TAVI between January 2017 and June 2019 was extracted from a prospective database. Preoperative, intraoperative and postoperative characteristics were analyzed by univariate analysis followed by logistic regression to find predictors of the occurrence of stroke or death within the first 30 days after the procedure.

RESULTS

Incidence of stroke within 30 days post-TAVI was 4.9%, [CI 95% 3.3-7.2], i.e., 25 strokes. Four out of the 25 patients (16%) with a stroke died within 30 days post-TAVI. After logistic regression analysis, the predictors of early stroke related to TAVI were: CHA2Ds2VASc score ≥ 5 (odds ratio [OR] 2.62; 95% CI: 1.06-6.49; p = .037), supra-aortic access vs. femoral access (OR: 9.00, 95%CI: 2.95-27.44; p = .001) and introduction post-TAVI of a single vs. two or three antithrombotic agents (OR: 5.13; CI 95%: 1.99 to 13.19; p = .001). Over the 30-day period, bleeding occurred in 28 patients (5.5%), in 25 of whom, it was associated with femoral or iliac artery access injury. Anti-thrombotic regimen was not associated with bleeding; two patients out of 48 (4.1%) bled with a single anti-thrombotic regimen vs. 26 patients out of 458 (5.6%) with a dual or triple anti-thrombotic regimen (p = 0.94). The overall 30-day mortality rate was 3.9%, [95% CI 2.5-6.0]. Patients with a single post-TAVI antithrombotic agent (OR: 44.07 [CI 95% 13.45-144.39]; p < .0001) and patients with previous coronary artery bypass surgery or coronary artery stenting (OR: 6.16, [CI 95% 1.99-21.29]; p = .002) were at significantly higher risk of death within the 30-day period.

CONCLUSION

In this large-scale single-center retrospective study, a single post-TAVI antithrombotic regimen independently predicted occurrence of early stroke or death. Dual or triple antithrombotic regimen was not associated with a higher risk of bleeding and should be considered as an option in patients undergoing TAVI.

Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, open-label, single centre, randomised-controlled, two-by-two factorial trial

BACKGROUND

Two billion peripheral venous catheters are sold globally each year, but the optimal skin disinfection and types of devices are not well established. We aimed to show the superiority of disinfection with 2% chlorhexidine plus alcohol over 5% povidone iodine plus alcohol in preventing infectious complications, and of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes used in combination (innovation group) over open catheters and three-way stopcocks for treatment administration (standard group) in preventing catheter failure.

METHODS

We did an open-label, randomised-controlled trial with a two-by-two factorial design, for which we enrolled adults (age ≥18 years) visiting the emergency department at the Poitiers University Hospital, France, and requiring one peripheral venous catheter before admission to the medical wards. Before catheter insertion, patients were randomly assigned (1:1:1:1) using a secure web-based random-number generator to one of four treatment groups based on skin preparation and type of devices (innovative devices or standard devices; 2% chlorhexidine plus alcohol or 5% povidone iodine plus alcohol). Primary outcomes were the incidence of infectious complications (local infection, catheter colonisation, or bloodstream infections) and time between catheter insertion and catheter failure (occlusion, dislodgment, infiltration, phlebitis, or infection). This study is registered with ClinicalTrials.gov, NCT03757143.

FINDINGS

1000 patients were recruited between Jan 7, and Sept 6, 2019, of whom 500 were assigned to the chlorhexidine plus alcohol group and 500 to the povidone iodine plus alcohol group (250 with innovative solutions and 250 with standard devices in each antiseptic group). No significant interaction was found between the two study interventions. Local infections occurred less frequently with chlorhexidine plus alcohol than with povidone iodine plus alcohol (0 [0%] of 496 patients vs six [1%] of 493 patients) and the same was observed for catheter colonisation (4/431 [1%] vs 70/415 [17%] catheters among the catheters cultured; adjusted subdistribution hazard ratio 0·08 [95% CI 0·02-0·18]). Median time between catheter insertion and catheter failure was longer in the innovation group compared with the standard group (50·4 [IQR 29·6-69·4] h vs 30·0 [16·6-52·6] h; p=0·0017). Minor skin reactions occurred in nine (2%) patients in the chlorhexidine plus alcohol group and seven (1%) patients in the povidone iodine plus alcohol group.

INTERPRETATION

For skin antisepsis, chlorhexidine plus alcohol provides greater protection of peripheral venous catheter-related infectious complications than does povidone iodine plus alcohol. Use of innovative devices extends the catheter complication-free dwell time.

FUNDING

Becton Dickinson.

Intracerebral hemorrhage in CADASIL

BACKGROUND

Intracerebral hemorrhage (ICH) has been reported in few cases of Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), mostly in hypertensive patients. We aimed to assess the clinical and radiological characteristics of patients with CADASIL who presented with ICH.

METHODS

A retrospective analysis of all neuroimaging exams of CADASIL patients hospitalized in our academic neurology department for acute cerebrovascular events was performed to find ICH. A systematic review of the literature was performed on this topic.

RESULTS

Including our five patients, a total number of 52 subjects with CADASIL and ICH (mean age: 56 years, SD 11, 36-69%- male) were reported. Intracerebral hemorrhages were mainly deep (34 subjects), followed by lobar (8 subjects), infratentorial (6 subjects) and mixed locations (4 subjects). Three ICHs were asymptomatic. Fourteen patients were taking antithrombotic medication, 18 had no regular antiplatelet or anticoagulant treatment while in 20 patients medical treatment was not detailed. Arterial hypertension was present in 37 out of 51 patients with available information. Neuroimaging showed extensive FLAIR hyperintensities in all CADASIL subjects with ICH, cerebral microbleeds in all but three patients, and lacunar infarction in 19 out of 25 subjects with available information.

CONCLUSIONS

Intracerebral hemorrhage represents a possible yet uncommon manifestation of CADASIL and should be considered as a possibility in patients with ICH associated with leukoencephalopathy and microbleeds, even in the absence of other clinical symptoms.

SiPP (Stroke in Pregnancy and Postpartum): A prospective, observational, international, multicentre study on pathophysiological mechanisms, clinical profile, management and outcome of cerebrovascular diseases in pregnant and postpartum women

Rationale

Cerebrovascular diseases associated with pregnancy and postpartum period are uncommon; however, they can have an important impact on health of both women and foetus or newborn.

Aims

To evaluate the frequency, characteristics and management of cerebrovascular events in pregnant/postpartum women, to clarify pathophysiological mechanisms underlying the occurrence of these events including biomolecular aspects, and to assess the short- and long-term cerebrovascular and global cardiovascular outcome of these patients, their predictors and infant outcome.

Methods and design

This is an observational, prospective, multicentre, international case-control study. The study will include patients with cerebrovascular events during pregnancy and/or within six months after delivery. For each included case, two controls will be prospectively recruited: one pregnant or puerperal subject without any history of cerebrovascular event and one non-pregnant or non-puerperal subject with a recent cerebrovascular event. All controls will be matched by age, ethnicity and type of cerebrovascular event with their assigned cases. The pregnant controls will be matched also by pregnancy weeks/trimester. Follow-up will last 24 months for the mother and 12 months for the infant.

Summary

To better understand causes and outcomes of uncommon conditions like pregnancy/postpartum-related cerebrovascular events, the development of multisite, multidisciplinary registry-based studies, such as the Stroke in Pregnancy and Postpartum study, is needed in order to collect an adequate number of patients, draw reliable conclusions and give definite recommendations on their management.

Transcranial Doppler to detect right-to-left shunt in cryptogenic acute ischemic stroke

OBJECTIVES

We aimed to confirm the sensitivity and specificity of contrast transcranial Doppler (cTCD) in the detection of right-to-left shunt (RLS) compared to the current reference standard (i.e., transesophageal echocardiography-TEE) in patients aged <55 years with a cryptogenic acute ischemic stroke (AIS) or high-risk (ABCD² score ≥4) transient ischemic attack (TIA), and to calculate the real life delay in detecting RLS by cTCD versus TEE in a tertiary care academic stroke center.

METHODS

Consecutive 16- to 54-year-old patients with AIS or high-risk TIA underwent complete diagnostic workup which included, in case of undetermined etiology, cTCD and TEE. Sensitivity and specificity of cTCD, RLS characteristics, and median delay between the two tests were calculated.

RESULTS

Of the 98 included patients, 52 (53%) had a cryptogenic cerebrovascular ischemic event, which displayed a 56% prevalence of RLS related to a patent foramen ovale (PFO) mainly with a high-grade shunt. When comparing TCD with "bubble test" to TEE, sensitivity and specificity were both 100%. Median delays from symptom onset to examination were 2 (min-max 1-10) and 21 (min-max 1-60) days, respectively, for cTCD and TEE. No adverse event occurred during or after cTDC examination.

CONCLUSIONS

Transcranial Doppler with "bubble test" appears as the best screening test for the detection of RLS in young and middle-aged adults with cryptogenic acute cerebral ischemic events to select patients potentially suitable for closure procedure after TEE confirmation.

Should We Screen for Janus Kinase 2 V617F Mutation in Cerebral Venous Thrombosis?

BACKGROUND

The presence of Janus Kinase 2 (JAK2) V617F mutation represents a major diagnostic criterion for detecting myeloproliferative neoplasms (MPN) and even in the absence of overt MPN, JAK2 V617F mutation is associated with splanchnic vein thrombosis. However, the actual prevalence and diagnostic value of the JAK2 V617F mutation in patients with cerebral venous thrombosis (CVT) are not known. The aims of this study were to assess the prevalence of JAK2 V617F mutation in a large group of consecutive CVT patients, to detect clinical, biological, and radiological features associated with the mutation, and to determine the long-term venous thrombosis recurrence rate in CVT patients with JAK2 mutation but without overt MPN in order to recommend the best preventive treatment.

METHODS

This was a prospective study conducted on consecutive patients with a first-ever radiologically confirmed CVT. JAK2 V617F mutation analysis was assessed in all the study subjects. JAK2 V617F-positive patients were followed up to detect new venous thrombotic events.

RESULTS

Of the 125 included subjects, 7 were found to have JAK2 V617F mutation (5.6%; 95% CI 2.3-11.2). Older age (p = 0.039) and higher platelet count (p = 0.004) were independently associated with JAK2 V617F positivity in patients without overt MPN. During a mean follow-up period of 59 (SD 46) months, 2 JAK2 V617F-positive patients presented with 4 new venous thromboembolic events.

CONCLUSIONS

Screening for the JAK2 V617F mutation in CVT patients seems to be useful even in the absence of overt MPN and/or in the presence of other risk factors for CVT because of its relatively high prevalence and the risk of thrombosis recurrence.

Venous Thrombotic Recurrence After Cerebral Venous Thrombosis

Background and Purpose—

After cerebral venous thrombosis (CVT), the risk of venous thrombotic events was estimated at 2% to 3% for a new CVT and 3% to 8% for extracranial events. However, because of the paucity of prospective studies, the clinical course of CVT is still largely unknown. We aimed to prospectively evaluate the rate of thrombosis recurrence in a cohort of CVT patients with a long-term follow-up and to detect predisposing factors for recurrence.

Methods—

Consecutive CVT patients with complete clinical, radiological, biological, and genetic data were systematically followed up. New venous thrombotic events were detected after hospital readmission and imaging confirmation.

Results—

One-hundred eighty-seven patients (mean age 45±18 years, 67% women) with angiographically confirmed CVT were included. Cause was found in 73% of patients. Coagulation abnormality and JAK2 gene mutation were detected in 20% and 9%, respectively. Median follow-up length was 73 months (range 1–247 months). Mean duration of the oral anticoagulant treatment was 14 months. Mortality rate was 2.5% per year, with 2% in-hospital mortality. During follow-up, CVT reoccurred in 6 patients, whereas 19 subjects had a symptomatic extracranial venous thrombotic event, with cumulative venous thrombotic recurrence rates of 3% at 1 year, 8% at 2 years, 12% at 5 years, and 18% at 10 years. A previous venous thrombotic event (hazard ratio, 2.8; P =0.018), presence of cancer or malignant hemopathies (hazard ratio, 3.2; P =0.039), and unknown CVT causes (hazard ratio, 2.81; P =0.024) were independently associated with recurrence.

Conclusions—

In our cohort of CVT patients followed on average for >6 years, subjects with a previous venous thrombotic event, cancer/malignant hemopathies, and unknown CVT causes were found to be at higher risk of recurrence.

Long-term outcome of basilar stenosis in Erdheim-Chester disease: A case report

BACKGROUND

Erdheim-Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis. This inflammatory myeloid neoplasm is frequently complicated by neurological symptoms, but stroke is an exceptional manifestation of this disease.

METHODS

We report the case of a 59-year-old woman who presented a vertebrobasilar stroke secondary to infiltration and severe stenosis of the basilar artery, improved after interferon-alpha therapy. We performed a review of the relevant literature and reported the few other cases described.

RESULTS

With our patient, we have found only 7 observations of cerebrovascular disorder in ECD. Most of them had supravascular arteries involvement.

CONCLUSION

Stroke is a rare treatable and potentially reversible complication of ECD. The pathophysiological processes explaining stroke in this disease are uncertain, but periarterial stenosis of cerebral arteries may be a mechanism.

Posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome after bilateral carotid paraganglioma resection: A case report

Background

Paraganglioma is a rare neuroendocrine tumour arising anywhere along the paravertebral sympathetic and parasympathetic chains. In the neck, paraganglioma may affect the carotid body (carotid body tumour).

Case report

We describe a 43-year-old woman who presented with a reversible vasoconstriction syndrome associated with a posterior reversible encephalopathy syndrome following a surgery for a left carotid paraganglioma (with a past medical history of surgery for a right carotid paraganglioma a few months before).

Conclusion

A consequence of a baroreflex modification is discussed in order to explain the rare occurrence of such symptoms.

Elevation of Plasma 2-Arachidonoylglycerol Levels in Alzheimer's Disease Patients as a Potential Protective Mechanism against Neurodegenerative Decline

BACKGROUND

Growing evidence suggests that the endocannabinoid system is involved in the pathogenesis of Alzheimer's disease (AD) and atherosclerosis.

OBJECTIVE

The purpose of this study was to investigate the activation of the endocannabinoid system in AD in vivo and the possible intermediate role of atherosclerosis.

METHODS

We enrolled 41 patients with probable AD, and 30 age- and gender-matched controls. All subjects underwent: ultrasound examination of cerebral and neck vessels (including intima-media thickness and plaque stenosis evaluation); blood sampling to measure levels of endocannabinoid [anandamide (AEA), 2-arachidonoylglycerol (2-AG)] and endogenous AEA analogues [N-palmitoyl-ethanolamide (PEA); N-oleoyl-ethanolamide]; neuropsychological evaluation and brain MRI (atrophy, white matter hyperintensity volume).

RESULTS

2-AG levels were higher in AD patients compared to controls (Mann-Whitney test p = 0.021). In the AD group, 2-AG correlated to white matter hyperintensity volume (r = 0.415, p = 0.015) and was higher in patients with chronic heart ischemic disease (p = 0.023). In AD patients, 2-AG was also positively related to memory (r = 0.334, p = 0.05) and attention (r = 0.423, p = 0.018) performances. Constructional praxia test scores were lower in patients with higher levels of PEA (r =-0.389, p = 0.019).

CONCLUSION

AD patients present high plasma 2-AG levels, also in relation to heart ischemic disease and cerebral leukoaraiosis. This may be a protective mechanism hindering neurodegeneration, but it may also play an ambivalent role on cerebrovascular circulation. The increase in 2-AG and PEA levels observed with ongoing pathological processes may differently modulate cognitive performances.

Direct stroke unit admission of intravenous tissue plasminogen activator: safety, clinical outcome, and hospital cost savings

BACKGROUND

In the USA, stable intravenous tissue plasminogen activator (IV tPA) patients have traditionally been cared for in an intensive care unit (ICU). We examined the safety of using an acuity-adaptable stroke unit (SU) to manage IV tPA patients.

METHODS

We conducted an observational study of consecutive patients admitted to our acuity-adaptable SU over the first 3 years of operation. Safety was assessed by symptomatic intracerebral hemorrhage (sICH) rates, systemic hemorrhage (SH) rates, tPA-related deaths, and transfers from SU to ICU; cost savings and length of stay (LOS) were determined.

RESULTS

We admitted 333 IV tPA patients, of which 302 were admitted directly to the SU. A total of 31 (10%) patients had concurrent systemic hemodynamic or pulmonary compromise warranting direct ICU admission. There were no differences in admission National Institutes of Health Stroke Scale scores between SU and ICU patients (9.0 versus 9.5, respectively). Overall sICH rate was 3.3% (n = 10) and SH rate was 2.9 (n = 9), with no difference between SU and ICU patients. No tPA-related deaths occurred, and no SU patients required transfer to the ICU. Estimated hospital cost savings were US$362,400 for 'avoided' ICU days, and hospital LOS decreased significantly (p = 0.001) from 9.8 ± 15.6 days (median 5) in year 1, to 5.2 ± 4.8 days (median 3) by year 3.

CONCLUSIONS

IV tPA patients may be safely cared for in a SU when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for monitoring may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.

Emerging Risk Factors for Dementia: The Role of Blood Pressure Variability

In the recent years, classical vascular risk factors have been suggested to play a role also in the development of degenerative dementia. Arterial hypertension has been implicated in the pathogenesis of dementia but no conclusive results have been produced yet; more recently, blood pressure variability (BPV) has been suggested as a more important risk factor for both silent brain vascular lesions and the development of dementia. Blood pressure variability is defined as the variation in blood pressure over time, measured on different time spans and in different ways. We reviewed current scientific literature about the role of BPV in the pathogenesis of dementia, and about the association of abnormal BPV patterns and different forms of dementia. We also suggested some hypothetical pathogenic mechanisms.

Abstract NS4: Vigilant Nursing Glucose and Temperature Control for Stroke: Is There a Need in the United States?

Background: In the Australian QASC Trial (Lancet 2013), better glucose and fever control improved 90 day outcomes when nurses adhered to strict monitoring/treatment protocols. We examined variance from guideline specific care for glucose and fever in an American sample.

Methods: An observational study was conducted to assess compliance with AHA/ASA stroke guidelines for glucose and fever control in consecutive acute stroke patients from 5 different U.S. Stroke Centers. The first 5-days of glucose/temperature data were analyzed along with demographics and outcome measures.

Results: A total of 1669 consecutive glucose and 3782 consecutive temperature measurements were taken from a sample of 235 acute stroke patients; the sample was 87% ischemic and 13% ICH, with admission median NIHSS 4.0 (range 0-34) and ICH score median 1 (range 0-5). 26% of ischemic strokes received IVtPA and/or thrombectomy. HbA1c was 5.7 + .65 (median range 4.8-11.2) in non-DM diagnosed patients vs. 8.3 + 2.3 (range 5.0-14.1; 95%CI=1.9-3.1; p<0.001) in DM patients. Glucose was >180 mg/dL for >4 hours in 33% during hospitalization (Table), and the most frequent method (35%) for glucose control was regular insulin sliding scale. Temperature was >37.5 o (noncompliant with European/Australian [E/A] standards) for >4 hours in 27% of patients, and >38 o (noncompliant with US standards) for >4 hours in 10% of patients; 8% were out-of-control >8 hours (range 9-96, median 16.5 hours out-of-control) and 39% did not have temperature measured in the ED. mRS and LOS were significantly worse if temperature exceeded the E/A and US standards (Table). Temperature control to <37.5 o C was an independent predictor (p<0.001) of favorable (0-2) mRS at discharge.

Conclusions: Our study underscores the need for more vigilant control of glucose and temperature by nurses at U.S. hospitals. Given the time-sensitive ability of brain to recover from ischemia, even short-term non-compliance may have detrimental effects.

Risk of pneumonia associated with zero-degree head positioning in acute ischemic stroke patients treated with intravenous tissue plasminogen activator

INTRODUCTION

In the hyperacute phase of ischemic stroke, a 0° position is recommended to increase cerebral perfusion in nonhypoxic patients able to tolerate lying flat. However, use of 0° positioning is not uniformly applied in clinical practice, most likely due to concerns of aspiration pneumonia. We aimed to determine the risk of pneumonia associated with 0° head of bed positioning in acute stroke patients treated with thrombolytic therapy.

METHODS

A retrospective descriptive study was conducted using prospectively collected, consecutive acute ischemic stroke patients treated with IVtPA whose head of bed was positioned at 0° for the first 24 h. Rates of hospital-acquired pneumonia were determined using a strict adjudication process to insure accuracy of pneumonia diagnoses. Quantitative characteristics were analyzed in SPSS to compare differences between "true" pneumonia cases and nonpneumonia cases.

RESULTS

Twenty-four of 333 (7.2%) patients had mention the diagnosis of pneumonia in the registry and/or medical record. Of these cases, only 15 (4.5%) met evidence-based diagnostic criteria for hospital-acquired pneumonia. The 15 adjudicated cases had similar median admission NIHSS scores to nonpneumonia cases (10 vs. 9, respectively; P = ns), but were older (74 ± 15 vs. 64 ± 17 years; mean difference 9.889, 95 CI = 1.2-18.6; P = 0.026). A total of eight patients with pneumonia were intubated and mechanically ventilated, and one patient received bilevel positive airway pressure ventilation during the 0° positioning period. Pneumonia cases had significantly longer hospitalizations (14.5 ± 12 vs. 6.6 ± 9 days; mean difference 7.97, 95% CI = 1.1-14.8; P = 0.026) and higher median discharge mRS score (4 vs. 3: P = 0.003).

CONCLUSIONS

Zero-degree head of bed positioning in the first 24 h following an acute ischemic stroke treated with IV-tPA was associated with acceptable rates of pneumonia. Rates for pneumonia may be further reduced by eliminating use of a 0° protocol in intubated/mechanically ventilated patients.

Cortical Ischemic Lesion Burden Measured by DIR Is Related to Carotid Artery Disease Severity

Background: Over time, exposure to cerebrovascular risk factors and carotid artery disease may cause multiple asymptomatic brain cortical and subcortical microinfarcts, which are commonly found at brain autopsy. So far, lack of convenient neuroimaging tools limited the investigation of grey matter ischemic damage in vivo. We applied the Double Inversion Recovery (DIR) sequence to explore the impact of carotid artery disease on intracortical ischemic lesion load in vivo, taking into account the impact of demographic characteristics and vascular risk factors. Methods: DIR was acquired in 62 patients with common cerebrovascular risk factors stratified in three groups according to carotid artery disease severity. Intracortical lesions scored on DIR (DIRlns) were classified by vascular territory, lobe and hemisphere. White matter hyperintensities (WMHs) volume was also quantified on Fluid Attenuated Inversion Recovery sequence (FLAIR). Results: Among demographic characteristics and cerebrovascular risk variables explored, General Linear Model indicated that age and carotid artery disease were significantly associated to DIRlns. After correcting for age, DIRlns load was found to be significantly dependent on carotid artery stenosis severity (F(2, 58) = 5.56, p = 0.006). A linear positive correlation between DIRlns and WMHs was found after correcting for age (p = 0.003). Conclusions: Carotid disease severity is associated with DIRlns accrual. Microembolism and impaired cerebral hemodynamics may act as physiopathological mechanisms underlying cortical ischemic damage. The role of other factors, such as small vessel disease and the possible interaction with carotid disease, remains to be further explored.

Do billing codes accurately capture intravenous tissue plasminogen activator treatment rates? Justified concern for clinical performance measures based on billing code assignment

BACKGROUND

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes are commonly used to determine US national stroke volume and intravenous (IV) tissue plasminogen activator (tPA) treatment rates; however, this method is often criticized because of assumed poor validity and reliability of coding assignment. We sought to understand the validity of IV tPA ICD-9-CM code assignments within a comprehensive stroke center in the southeastern United States.

METHODS

Confirmed stroke registry IV tPA cases were retrieved from 2009 to 2011; tPA drip and ship cases were eliminated from the analysis. Retained clinical data included admission National Institutes of Health Stroke Scale (NIHSS) scores, hemorrhagic transformation, diffusion positive magnetic resonance imaging (MRI) results, and discharge modified Rankin Scale (mRS) score.

RESULTS

A total of 247 IV tPA cases were assembled, of which 78% were appropriately assigned the IV tPA billing code. ICD-9 code 434.91 (cerebral artery occlusion with infarct) was used for 72% of the sample, 434.11 (cerebral emboli with infarct) was used for 9% of cases, and 433.11 (carotid occlusion with infarct) was assigned to 2% of cases. Interestingly, 435 (transient cerebral ischemia) was assigned to 2% (n = 7) with all of these cases having NIHSS score more than 2 at time of treatment, diffusion MRI documentation of infarction in 29%, and 43% having a discharge mRS score more than 2.

CONCLUSIONS

Our findings support the concern that billing codes may significantly underestimate actual IV tPA treatment volume in the United States and suggest the need for regular audit of billing codes by Stroke Center leaders, with provision of feedback and education to coders, aimed at improving code assignment.

Cerebrovascular reactivity predicts stroke in high-grade carotid artery disease

OBJECTIVE

To assess the usefulness of transcranial Doppler CO2 reactivity (CO2R) for prediction of ipsilateral ischemic stroke in carotid artery stenosis and occlusion with a meta-analysis of prospective studies based on individual patient data.

METHODS

We searched Medline, Biosis Previews, Science Citation Index, The Cochrane Library, and EMBASE for studies in which patients with severe carotid artery stenosis or occlusion underwent Doppler CO2R testing (inhalation of CO2 or breath-holding) and were prospectively followed for ipsilateral ischemic stroke. Individual data from 754 patients from 9 studies were included. We used percentage cerebral blood flow velocity increase (pCi) during hypercapnia as the primary CO2R measure, and defined impaired reactivity as pCi <20% increase.

RESULTS

In a multiple regression model, impaired CO2R was independently associated with an increased risk of ipsilateral ischemic stroke (hazard ratio [HR] 3.69; confidence interval [CI] 2.01, 6.77; p < 0.0001). Risk prediction was similar for recently symptomatic vs asymptomatic patients. Using continuous values of pCi, a significant association between decreasing pCi and increasing risk of ipsilateral stroke was found: HR of 1.64 (95% CI 1.33, 2.02; p < 0.0001) per 10% decrease in pCi. For patients with asymptomatic internal carotid artery stenosis only (n = 330), a comparable stroke risk prediction was found: increasing HR 1.95 (95% CI 1.26, 3.04; p = 0.003) per 10% decrease in pCi.

CONCLUSIONS

This analysis supports the usefulness of CO2R in risk prediction for patients with severe carotid artery stenosis or occlusion, both in recently symptomatic and asymptomatic patients. Further studies should evaluate whether treatment strategies in asymptomatic patients based on CO2R could improve patient outcomes.

Investigating the utility of previously developed prediction scores in acute ischemic stroke patients in the stroke belt

BACKGROUND

To assess the utility of previously developed scoring systems, we compared SEDAN, named after the components of the score (baseline blood Sugar, Early infarct signs and (hyper) Dense cerebral artery sign on admission computed tomography scan, Age, and National Institutes of Health Stroke Scale on admission), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-arterial Therapy (HIAT), and HIAT-2 scoring systems among patients receiving systemic (intravenous [IV] tissue plasminogen activator [tPA]) and endovascular (intra-arterial [IA]) treatments.

METHODS

We retrospectively reviewed all IV tPA and IA patients presenting to our center from 2008-2011. The scores were assessed in patients who were treated with IV tPA only, IA only, and a combination of IV tPA and IA (IV-IA). We tested the ability of THRIVE to predict discharge modified Rankin scale (mRS) 3-6, HIAT and HIAT-2 discharge mRS 4-6, and SEDAN symptomatic intracerebral hemorrhage (sICH).

RESULTS

Of the 366 patients who were included in this study, 243 had IV tPA only, 89 had IA only, and 34 had IV-IA. THRIVE was predictive of mRS 3-6 in the IV-IA (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.30-2.91) and the IV group (OR, 1.71; 95% CI, 1.43-2.04), but not in the IA group. HIAT was predictive of mRS 4-6 in the IA (OR, 3.55; 95% CI, 1.65-7.25), IV (OR, 3.47; 95% CI, 2.26-5.33), and IV-IA group (OR, 6.48; 95% CI, 1.41-29.71). HIAT-2 was predictive of mRS 4-6 in the IA (OR, 1.39; 95% CI, 1.03-1.87) and IV group (OR, 1.36; 95% CI, 1.18-1.57), but not in the IV-IA group. SEDAN was not predictive of sICH in the IA or the IV-IA group, but was predictive in the IV group (OR, 1.54; 95% CI, 1.01-2.36).

CONCLUSIONS

Our study demonstrated that although highly predictive of outcome in the original study design treatment groups, prediction scores may not generalize to all patient samples, highlighting the importance of validating prediction scores in diverse samples.

Acute hyperglycemia reduces cerebrovascular reactivity: the role of glycemic variability

CONTEXT

Cerebral vasomotor reactivity (CVR) is reduced in patients with diabetes mellitus (DM), and glucose variability (GV) might be responsible for cerebrovascular damage.

OBJECTIVE

Studying patients with insulin resistance without DM, we explored the role of GV in impairing CVR.

PATIENTS

We studied 18 metabolic syndrome (MS) patients without DM, 9 controls (C), and 26 patients with DM.

MAIN OUTCOME MEASURES

Groups were compared in terms of CVR, GV, and 24-hour blood pressure. To evaluate the impact of acute hyperglycemia on CVR, a hyperglycemic clamp was performed in MS patients and controls.

RESULTS

Baseline CVR was reduced in DM vs C and MS (C vs DM = 20.2, 95% CI = 3.5-36.9, P = .014; and MS vs DM = 22.2, 95% CI = 8.6-35.8, P = .001), but similar between MS and C (MS vs C = 2.0, 95% CI = -14.7 to 18.7, P = .643). During acute hyperglycemia, CVR fell in MS and C to values comparable to DM. GV progressively increased from C to MS to DM. In MS, CVR at 120 minutes and GV displayed a negative correlation (r = -0.48, P = .043), which did not change after controlling for mean 24-hour systolic and diastolic blood pressure. In MS, the CVR reduction was significantly correlated to GV (r = 0.55, P = .02).

CONCLUSIONS

GV is increased in patients with MS but without DM and is the major predictor of CVR reduction induced by acute hyperglycemia, possibly representing the earliest cause of cerebrovascular damage in DM.

Racial disparities in early mortality in 1,134 young patients with acute stroke

We sought to investigate potential racial disparities in early outcomes of young individuals with stroke in an international multicenter study. We evaluated consecutive patients with first-ever acute stroke aged 18-45 years from prospective databases involving 12 tertiary-care stroke centers in North America (n = 2), Europe (n = 6), and Asia (n = 4). Demographics, vascular risk factors, stroke subtypes, pre-stroke functional status, stroke severity, blood pressure parameters, and serum glucose at hospital admission were documented. The outcome events of interest were 30-day mortality and 30-day favorable functional outcome (FFO) defined as modified-Rankin Scale score of 0-1. A total of 1,134 young adults (mean age 37.4 ± 7.0 years; 58.8 % men; 48.6 % Whites, 23.9 % Blacks, and 27.5 % Asians; median baseline National Institutes of Health Stroke Scale score 6 points, interquartile range 2-13) were included in the analyses. The 30-day stroke mortality and FFO rates differed (p < 0.001) across races. After adjusting for potential confounders, race was independently associated with 30-day mortality (p = 0.026) and 30-day FFO (p = 0.035). Blacks had a fourfold higher odds of 30-day stroke mortality in comparison to Asians (OR 4.00; 95 % CI 1.38-11.59; p = 0.011). Whites also had an increased likelihood of 30-day stroke mortality in comparison to Asians (OR 3.59; 95 % CI 1.28-10.03; p = 0.015). Blacks had a lower odds of 30-day FFO in comparison to Whites (OR 0.57; 95 % CI 0.35-0.91; p = 0.018). Racial disparities in early outcomes following first-ever stroke in young individuals appear to be independent of other known outcome predictor variables. Whites appear to have higher likelihood of 30-day FFO and Asians have lower odds of 30-day stroke mortality.

Basilar artery thrombus vs. fenestration: a differential diagnostic challenge in acute ischemic stroke

We present a case of a man presenting with vertigo and nausea who was found to have multifocal infarcts in the posterior circulation on magnetic resonance imaging (MRI). An magnetic resonance angiography (MRA) demonstrated focal widening and central signal dropout in the distal vertebral artery consistent with arterial fenestration. Transcranial Doppler ultrasonography showed turbulent flow and a spike waveform suggestive of an intra-luminal thrombus. This was confirmed by computed tomography (CT) angiography. Following the initiation of dual antiplatelet therapy, the signal abnormalities on transcranial doppler (TCD) resolved suggesting dissolution of the thrombus. This case highlights the diagnostic pitfalls that may arise when relying on only one modality for assessing intracranial vasculature and the importance of clarifying the diagnosis of basilar thrombosis or fenestration.

Hypercapnia affects the functional coupling of resting state electroencephalographic rhythms and cerebral haemodynamics in healthy elderly subjects and in patients with amnestic mild cognitive impairment

OBJECTIVE

Cerebral vasomotor reactivity (VMR) and coherence of resting state electroencephalographic (EEG) rhythms are impaired in Alzheimer's disease (AD) patients. Here we tested the hypothesis that these two variables could be related.

METHODS

We investigated VMR and coherence of resting state EEG rhythms in nine normal elderly (Nold) and in 10 amnesic mild cognitive impairment (MCI) subjects. Resting state eyes-closed EEG data were recorded at baseline pre-CO₂ (ambient air, 2 min), during 7% CO₂/air mixture inhalation (hypercapnia, 90 s) and post-CO₂ (ambient air, 2 min) conditions. Simultaneous frontal bilateral near-infrared spectroscopy (NIRS) was performed to assess VMR by cortical oxy- and deoxy-haemoglobin concentration changes. EEG coherence across all electrodes was computed at delta (2-4 Hz), theta (4-8 Hz), alpha 1 (8-10.5 Hz), alpha 2 (10.5-13 Hz), beta 1 (13-20 Hz), beta 2 (20-30 Hz) and gamma (30-40 Hz) bands.

RESULTS

In Nold subjects, 'total coherence' of EEG across all frequency bands and electrode pairs decreased during hypercapnia, with full recovery during post-CO₂. Total coherence resulted lower in pre-CO₂ and post-CO₂ and presented poor reactivity during CO₂ inhalation in MCI patients compared with Nold subjects. Hypercapnia increased oxy-haemoglobin and decreased deoxy-haemoglobin concentrations in both groups. Furthermore, the extent of changes in these variables during CO₂ challenge was correlated with the EEG coherence, as a reflection of neurovascular coupling.

CONCLUSIONS

Hypercapnia induced normal frontal VMR that was detected by NIRS in both Nold and amnesic MCI groups, while it produced a reactivity of global functional coupling of resting state EEG rhythms only in the Nold group.

SIGNIFICANCE

In amnesic MCI patients, global EEG functional coupling is basically low in amplitude and does not react to hypercapnia.

Wheat IgE profiling and wheat IgE levels in bakers with allergic occupational phenotypes

OBJECTIVES

To characterise occupational wheat allergic phenotypes (rhino-conjunctivitis, asthma and dermatitis) and immunoglobulin (IgE) sensitisation to particular wheat allergens in bakers.

METHODS

We conducted clinical and immunological evaluations of 81 consecutive bakers reporting occupational symptoms using commercial tests (skin prick test (SPT), specific IgE, ISAC microarray) and six additional dot-blotted wheat allergens (Tri a 39, Tri a Trx, Tri a GST, Tri a 32, Tri a 12, Tri a DH).

RESULTS

Wheat SPT resulted positive in 29 bakers and was associated with work-related asthma (p<0.01). Wheat IgE was detected in 51 workers and was associated with work-related asthma (p<0.01) and rhino-conjunctivitis (p<0.05). ISAC Tri a 30 was positive in three workers and was associated with work-related dermatitis (p<0.05). Wheat dot-blotted allergens were positive in 22 bakers. Tri a 32 and Tri a GST were positive in 13 and three bakers, respectively, and both were associated with work-related dermatitis (p<0.05). This association increased (p<0.01) when Tri a 32, Tri a GST and Tri a 30 were analysed together (p<0.01). Wheat IgE levels were associated with work-related dermatitis (p<0.01).

CONCLUSIONS

Wheat IgE levels and wheat microarrayed allergens may be associated with some occupational allergic phenotypes. The extension of the panel of wheat allergens may be promising for discriminating the clinical manifestations of baker's allergy.

Lipid transfer proteins: the most frequent sensitizer in Italian subjects with food-dependent exercise-induced anaphylaxis

BACKGROUND

Specific food-dependent exercise-induced anaphylaxis (S-FDEIAn) is a distinct form of food allergy in which symptoms are elicited by exercise performed after ingesting food to which the patient has become sensitised. Non-specific FDEIAn (NS-FDEIAn) is a syndrome provoked by exercise performed after ingesting any food.

OBJECTIVE

We sought to identify the culprit allergenic molecules in patients with FDEIAn, combining 'classic' allergy testing with an allergenic molecule-based microarray approach for IgE detection.

METHODS

All subjects were evaluated who reported at least one episode of anaphylaxis in association with physical exercise performed within 4 h after a meal. We performed skin prick tests (SPT) with commercial food extracts, prick plus prick tests (P + P) with fresh foods (P + P), and serum specific IgE assays by means of both the ImmunoCAP (CAP) and the ISAC 89 microarray system (ISAC).

RESULTS

Among our 82 FDEIAn patients, the most frequent suspected foods were tomato, cereals, and peanut. SPT, P + P, and CAP displayed different degrees of sensitivity. Each test disclosed some positivities not discovered by others. Seventy-nine subjects were positive to at least one food (49 to more than 20), whereas three were negative. All suspected foods were positive to at least one of SPT, P + P, and CAP. When tested using the ISAC, 64 (78%) subjects were positive to Pru p 3 [peach lipid transfer protein (LTP)], 13 were positive to other food allergen molecules, and five displayed negative results to all food allergenic molecules. Overall, 79 patients probably had S-FDEIAn and the other 3 NS-FDEIAn.

CONCLUSIONS

Multiple food hypersensitivity represents a clinical hallmark of a large percentage of FDEIAn patients. The very high prevalence of IgE to the LTP suggests a role of this allergen group in causing S-FDEIAn.

Abstract 5: Management Of Intravenous tPA In Non-ICU Environments: Safety, Clinical Outcome, And Cost Savings

Background: Administration of IV tPA has traditionally necessitated admission to an ICU solely for monitoring, with relatively no need for extensive critical care services. Stroke Units that are capable of monitoring IV tPA patients have been proposed to reduce ICU use, but limited data exist that demonstrate safety. We report the largest series of non-ICU managed tPA cases in relation to safety and discharge outcomes.

Methods: Consecutive cases admitted to our intermediate-level Stroke Unit spanning 2009-2011 were assembled. Unit capabilities include IV tPA management with nicardipine infusion for blood pressure control as needed, non-invasive or direct central/arterial line and cardiac monitoring, and BiPAP ventilation. Stroke Unit nurses underwent extensive orientation and participate in NET SMART Junior for continuing education. Overall sICH, and drip/ship sICH (parenchymal hemorrhage in combination with > 4 point increase on the NIHSS), systemic hemorrhage, and tPA related death rates were calculated, along with discharge mRS and total ICU cost savings per day.

Results: A total of 302 Stroke Unit admissions for intravenous tPA occurred over the 3 year period, while another 31 (10%) were excluded due to critical care admission for systemic hemodynamic or pulmonary instability. Nicardipine infusions were used in 9 (10.5%) Stroke Unit tPA cases in 2009, 10 (9%) in 2010, and 14 (13%) in 2011. Overall sICH rate was 3.3% (n=10) and systemic hemorrhage rate was 2.9% (n=9) with 5 of these (56%) requiring transfusion. Estimated cost savings in total for this 3 year period was $362,400 for “avoided” ICU days.

Conclusions: Intravenous tPA patients may be safely managed on non-ICU Stroke Units when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for management of tPA monitoring needs may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.

Abstract TP70: Safety of IV tPA Administration with CT Evidence of Prior Infarction

Background: Prior stroke within 3 months excludes patients from thrombolysis, however patients may have CT evidence of prior infarct often of unknown time of origin. We aimed to determine if the presence of a previous infarct on pre-treatment head CT is a predictor of hemorrhagic complications following administration of IV tPA.

Methods: We retrospectively analyzed the database of consecutive patients treated with IV tPA at our institution from 2009-2011. Pre-treatment CTs were reviewed without knowledge of subsequent hemorrhagic transformation (HT) for evidence of any prior infarct. Further independent review determined if any HT was present on repeat CT or MRI. Symptomatic ICH (sICH) was defined as the presence of parenchymal hematoma (PH-1 or PH-2) and neurological deterioration by ≥ 4 points within 36 hours.

Results: Of 212 IV tPA treated patients, 72 (34%) had evidence of prior infarct on pre-treatment CT. Any HT was found in 16%, sICH occurred in 2.4% of the total population, and both events never occurred in the areas of prior infarcts. Patients with prior infarcts on CT were older (median age 72 vs 65; p=0.001), were more likely to have a history of hypertension (85% vs 71%; p=0.024), were on antiplatelet agents prior to admission (49% vs 31%; p=0.007) and had higher pre-treatment NIHSS scores (median 10 vs 7; p=0.023). Patients with prior infarcts on CT did not experience more HT (p=0.3956) nor sICH (p=0.2207), even after stratifying for prior lacunar or cortical stroke appearances (p=0.301). More patients with prior infarcts on CT had microbleeds on follow-up MRI (25% vs 11%; p=0.033), and patients with prior infarcts and microbleeds experienced more HT (63% vs. 10%; p<0.0001) but did not have more sICH (p=0.4784).

Conclusions: Visualization of prior infarcts on pre-treatment CT does not predict an increased risk of sICH and should not be viewed as a contraindication for systemic tPA treatment after clinically evident strokes within 3 months were excluded. A subgroup of patients with prior infarcts and subsequently discovered cerebral microbleeds show a propensity to develop asymptomatic HT.

Abstract WMP78: Investigating the Utility of Previously Developed Prediction Scores in AIS patients in the Stroke Belt

Background: A number of scoring systems have been developed in different geographic and treatment populations, however, it remains unknown how these scores perform in the Stroke Belt population. We sought to validate and assess the utility of the SEDAN, THRIVE, HIAT and HIAT2 scoring systems among patients receiving systemic (IV tPA) and endovascular (IAT) reperfusion.

Methods: We retrospectively reviewed all IV tPA and IAT patients presenting to our tertiary care center from 2009-2011. The scores were assessed in IV tPA only patients, IAT only patients and in patients who received both therapies (IV-IA). We tested THRIVE for predicting mRS 3-6, HIAT and HIAT2 for mRS 4-6, and SEDAN for symptomatic intracerebral hemorrhage (sICH). sICH was defined as a Type 2 parenchymal hemorrhage with deterioration in NIHSS score of 4 points or death. ROC curves were used to evaluate each score within the three groups.

Result: Of the 366 patients who were included in this study, 89 had IAT only, 243 had IV tPA only and 34 had IV-IA. Figure 1a shows their demographic and baseline characteristics. Figure 1b shows the performance of SEDAN, THRIVE, HIAT and HIAT2 scores in our population (ROC range from 0.512-0.818).

Conclusion: The two scores developed in the Stroke Belt, HIAT and HIAT2, performed well in the patient group for which they were developed (IAT). Additionally, they are also good predictors in other groups (IV and IV-IA). THRIVE performed well for predicting mRS 3-6 in all three groups. SEDAN was only moderately useful in predicting sICH after IV tPA. SEDAN had poor predictive value in IAT and IV-IA. These results highlight the need for validating clinical scores in different patient populations to determine their generalizability to all stroke patients.

Lack of correlation between cerebral vasomotor reactivity and flow-mediated dilation in subjects without vascular disease

Cerebral vasomotor reactivity (CVR) represents the capability of cerebral vessels to modify their caliber in response to a stimulus. Impaired CVR is associated with an increased risk for ischemic events in patients with carotid disease. Endothelial dysfunction is considered an important pathogenic factor for atherosclerosis and can be noninvasively assessed by flow-mediated vasodilation (FMD) evaluation. We aimed to evaluate both CVR and FMD in patients without histories of vascular disease in order to define a possible correlation. FMD was measured as brachial artery flow and diameter changes induced by transient ischemia. CVR to hypercapnia was assessed in all subjects by means of a breath-holding test and, in 20 subjects, by an additional CO(2) inhalation test. In 30 healthy volunteers (60% women, mean age 56 ± 6 years), CVR and FMD did not appear to be correlated (p = 0.444). A strong association between CO(2)-induced CVR and breath-holding index was observed (p < 0.001). CVR and FMD represent 2 different modalities that evaluate vasomotor function. According to our data, they did not appear to correlate, probably due to physiologic differences between cerebral and peripheral vascular districts and the vasodilatory stimulus used. The carbon dioxide-induced CVR and breath-holding index appeared to be significantly associated.

Allergens in allergy diagnosis: a glimpse at emerging new concepts and methodologies

Allergic diseases are important concern of public health. A reliable diagnosis is of utmost importance for the management of allergic patients both when immunotherapy is planned and when the treatment is essentially based on the avoidance of the allergy source. However, the available diagnostic systems sometimes fail to detect specific IgE antibodies thus impairing the correct diagnosis. The traditional test systems are generally based on the use of protein extracts derived from the allergenic sources whose composition is very variable and cannot be standardized. The development of a new methodology combining the so-called allergenic molecule-based diagnosis with the multiplex microarray technology and allowing the analysis of multiple purified allergens in a single test represents an important improvement in allergy diagnosis. In addition, the biochemical and immunological characterisation of individual allergens has provided new insights into the understanding of allergen-IgE recognition that could be exploited for further improvements of allergy diagnostic tests.

Tolerability of a fully maturated cheese in cow's milk allergic children: biochemical, immunochemical, and clinical aspects

BACKGROUND

From patients' reports and our preliminary observations, a fully maturated cheese (Parmigiano-Reggiano; PR) seems to be well tolerated by a subset of cow's milk (CM) allergic patients.

OBJECTIVE AND METHODS

To biochemically and immunologically characterize PR samples at different maturation stage and to verify PR tolerability in CM allergic children. Seventy patients, with suspected CM allergy, were enrolled. IgE to CM, α-lactalbumin (ALA), β-lactoglobulin (BLG) and caseins (CAS) were tested using ImmunoCAP, ISAC103 and skin prick test. Patients underwent a double-blind, placebo-controlled food challenge with CM, and an open food challenge with 36 months-maturated PR. Extracts obtained from PR samples were biochemically analyzed in order to determine protein and peptide contents. Pepsin and trypsin-chymotrypsin-pepsin simulated digestions were applied to PR extracts. Each PR extract was investigated by IgE Single Point Highest Inhibition Achievable assay (SPHIAa). The efficiency analysis was carried out using CM and PR oral challenges as gold standards.

RESULTS

The IgE binding to milk allergens was 100% inhibited by almost all PR preparations; the only difference was for CAS, mainly α(S1)-CAS. Sixteen patients sensitized to CM tolerated both CM and PR; 29 patients tolerated PR only; 21 patients, reacted to both CM and PR, whereas 4 patients reactive to CM refused to ingest PR. ROC analysis showed that the absence of IgE to BLG measured by ISAC could be a good marker of PR tolerance. The SPHIAa using digested PR preparations showed a marked effect on IgE binding to CAS and almost none on ALA and BLG.

CONCLUSIONS

58% of patients clinically reactive to CM tolerated fully maturated PR. The preliminary digestion of CAS induced by PR maturation process, facilitating a further loss of allergenic reactivity during gut digestion, might explain the tolerance. This hypothesis seems to work when no IgE sensitization to ISAC BLG is detected.

In planta expression of a mature Der p 1 allergen isolated from an Italian strain of Dermatophagoides pteronyssinus

European (Dermatophagoides pteronyssinus) and American (Dermatophagoides farinae) house dust mite species are considered the most common causes of asthma and allergic symptoms worldwide. Der p 1 protein, one of the main allergens of D. pteronyssinus, is found in high concentration in mites faecal pellets, which can became easily airborne and, when inhaled, can cause perennial rhinitis and bronchial asthma. Here we report the isolation of the Der p 1 gene from an Italian strain of D. pteronyssinus and the PVX-mediated expression of its mature form (I-rDer p 1) in Nicotiana benthamiana plants. Human sera from characterized allergic patients were used for IgE binding inhibition assays to test the immunological reactivity of I-rDer p 1 produced in N. benthamiana plants. The binding properties of in planta produced I-rDer p 1 versus the IgE of patients sera were comparable to those obtained on Der p 1 preparation immobilized on a microarray. In this paper we provide a proof of concept for the production of an immunologically active form of Der p 1 using a plant viral vector. These results pave the way for the development of diagnostic allergy tests based on in planta produced allergens.

Allergen micro-bead array for IgE detection: a feasibility study using allergenic molecules tested on a flexible multiplex flow cytometric immunoassay

BACKGROUND

Allergies represent the most prevalent non infective diseases worldwide. Approaching IgE-mediated sensitizations improved much by adopting allergenic molecules instead of extracts, and by using the micro-technology for multiplex testing.

OBJECTIVE AND METHODS

To provide a proof-of-concept that a flow cytometric bead array is a feasible mean for the detection of specific IgE reactivity to allergenic molecules in a multiplex-like way. A flow cytometry Allergenic Molecule-based micro-bead Array system (ABA) was set by coupling allergenic molecules with commercially available micro-beads. Allergen specific polyclonal and monoclonal antibodies, as well as samples from 167 allergic patients, characterized by means of the ISAC microarray system, were used as means to show the feasibility of the ABA. Three hundred and thirty-six sera were tested for 1 or more of the 16 selected allergens, for a total number of 1,519 tests on each of the two systems.

RESULTS

Successful coupling was initially verified by detecting the binding of rabbit polyclonal IgG, mouse monoclonal, and pooled human IgE toward three allergens, namely nDer s 1, nPen m 1, and nPru p 3. The ABA assay showed to detect IgE to nAct d 1, nAct d 11, rAln g 1, nAmb a 1, nArt v 3, rBet v 1, rCor a 1, nCup a 1, nDer p 1, nDer s 1, rHev b 5, nOle e 1, rPar j 2, nPen m 1, rPhl p 1, and nPru p 3. Results obtained by ABA IgE testing were highly correlated to ISAC testing (r = 0.87, p<0.0001). No unspecific binding was recorded because of high total IgE values.

CONCLUSION

The ABA assay represents a useful and flexible method for multiplex IgE detection using allergenic molecules. As also shown by our initial experiments with monoclonals and polyclonals, ABA is suitable for detecting other human and non-human immunoglobulins.

Abstract 2691: Multicenter, International Study of Stroke in the Young (MISSY): Initial Results on Racial Disparities in Early Outcomes

Background&Purpose: Strokes in young adults differ from cerebrovascular events in the general population due to a wider variety of etiopathogenic mechanisms as well as by incidence and outcomes. Limited data exist regarding racial disparities in stroke outcomes in this specific age subgroup. We sought to prospectively evaluate potential racial disparities in early outcomes of young individuals with stroke in a multicenter, international study.

Subjects&Methods: We prospectively evaluated consecutive first-ever stroke patients aged 18-45 years old who were admitted in 7 tertiary care stroke centers in North America (n=2), Europe (n=3) and Asia (n=2) over a four-year period (2008-2011). Demographics, vascular risk factors, etiopathogenic mechanism of stroke and stroke severity at hospital admission (assessed using the NIHSS-score) were documented. Early functional outcome at 1 month following stroke onset was evaluated using modified Rankin Scale (mRS) score.

Results: A total of 826 young adults (mean age 37±7years; 60% men; 49% Caucasians, 19% African-Americans and 32% Asians; median baseline NIHSS-score 6 points, interquartile range 3-14) have been evaluated during the study period with first-ever ischemic (84%) or hemorrhagic (16%) stroke. Baseline stroke severity differed between Caucasians (median NIHSS-score 4 points, interquartile range 2-10), African-Americans (median NIHSS-score 7 points, interquartile range 3-15) and Asians (median NIHSS-score 9 points, interquartile range 5-14; p<0.0001 by Kruskal-Wallis test). Early favorable functional outcome (defined as a 30-day mRS-score of 0-1) was different among racial subgroups (59% in Caucasians, 38% in African-Americans and 36% in Asians; p<0.0001). Race was independently (p=0.017) associated with functional outcome in multivariate logistic regression models adjusting for age, gender, vascular risk factors, baseline stroke severity and stroke subtype. Asian young adults with stroke were less likely to achieve an early favorable outcome (OR: 0.42, 95%CI: 0.22-0.79; p=0.008) compared to Caucasians. The former association was not significant for African-Americans (OR: 0.93, 95%CI: 0.55-1.55; p=0.767) compared to Caucasians.

Conclusions: Racial disparities in early functional outcome following first-ever stroke in young individuals appear to be independent of other known outcome predictor variables. Asian young adults with stroke tend to have a lower likelihood to achieve functional independence at 30 days following stroke onset. The underlying mechanisms of the former association deserve further investigation.

Ovomucoid (Gal d 1) specific IgE detected by microarray system predict tolerability to boiled hen's egg and an increased risk to progress to multiple environmental allergen sensitisation

BACKGROUND

Egg allergy is a very common finding in early childhood. Detecting hen's egg (HE) allergy outgrowing and reintroduction of food containing egg is a task for the allergist.

OBJECTIVE

We sought to evaluate the suitability of boiled egg food challenge compared with IgE to allergenic molecules from HE white using a microarray system.

METHOD

Sixty-eight children referring to our centre by the family paediatricians for a suspected egg allergy were enrolled. Patients underwent double-blind, placebo-controlled food challenge with boiled and raw eggs. Challenge outcomes were compared with skin tests performed using egg white and yolk commercial extracts, to prick-prick test with boiled and raw egg white and yolk, total IgE, egg white specific IgE detected using ImmunoCAP and IgE to egg allergens available on the immunosolid phase allergen chip (ISAC) 103 microarray.

RESULT

Nineteen subjects (28%) were reactive to both raw and boiled egg, 14 (20.5%) to raw egg only and 35 (51.4%) tolerated both boiled and raw egg. Efficiency analysis was carried out using both raw and boiled egg challenges as gold standard. Forty four of 47 Gal d 1 negative patients tolerated boiled egg (94%). Conversely, 20 of 21 Gal d 1 positive patients reacted to raw egg (95%). None of the other tests was able to discriminate patients' response to HE challenge. Furthermore, Gal d 1 positivity seems to lead to broader environmental allergen IgE sensitization.

CONCLUSION AND CLINICAL RELEVANCE

The Gal d 1 IgE reactivity appears to be a very good predictor of HE clinical allergy. Gal d 1 positive children have a high frequency of HE allergy, whereas Gal d 1 negative children have a high frequency of tolerance to boiled egg. Multiple specific IgE detection by means of ISAC improves the diagnostic approach in HE allergic children, disclosing other food and inhalant allergic sensitizations, anyhow requiring a comprehensive clinical evaluation.

Allergen micro-array detection of specific IgE-reactivity in Chinese allergy patients

BACKGROUND

Allergen micro-arrays are powerful tools for screening of serum IgE-reactivity. In this study allergen micro-arrays were used to identify dominating IgE-binding allergens and cross-reactivity patterns among selected Chinese allergy patients.

METHODS

The study was conducted using patient sera from the cities of Guangzhou, Nanjing, Chengdu and Shenyang. In total 100 sera with Dermatophagoides pteronyssinus (Der p) specific IgE-levels higher than 50 kU/L were selected for testing against 103 individual allergens.

RESULTS

Among 100 selected patients, 95% showed IgE-reactivity towards house-dust mite allergens Dermatophagoides farinae (Der f) 1, Der f 2 and Der p 2 and 94% were IgE positive against Der p 1, and 60% of sera contained IgE reacting against allergen Euroglyphus maynei (Eur m) 2. IgE against cat allergen, Felisdomesticus (Fel d) 1, was seen in 20%. Only 2% showed specific IgE-reactivity to Der p 10, a panallergen belonging to the tropomyosin family. Serum IgE-reactivity towards other allergens was in general low. IgE-reactivity against pollen allergens showed geographic differences.

CONCLUSIONS

This study clearly confirms that group 1 and group 2 are major allergens of house dust mites. These selected house-dust mite allergy patients are close to being mono-sensitized. Der p 10 is not an important allergen for cross-reactivity. Specific IgE-sensitization towards pollen allergens is low in southern China compared to other regions. The prevalence of food and stinging insect allergens known to give rise to IgE-mediated cross-reactivity is 2% or less.