A survey of preprocedural intubation practices for endovascular treatment of acute ischemic stroke.

BACKGROUND: In the absence of specific guidelines, there is considerable variance in preprocedural intubation practices for endovascular treatment of acute ischemic stroke. The purpose of this study is to understand and characterize the variance in preprocedural intubation practices and identify the reasons that influence the choice of preprocedural intubation practices among treating physicians. METHODS: We selected 10 random cases from a prospective database of patients undergoing endovascular treatment for acute ischemic stroke and prepared a case summary providing pertinent demographic, clinical, and imaging data. Twenty clinicians independently reviewed the case summaries and responded to whether they would intubate any of the 10 patients and identified the reasons for their choices. Clinicians were also asked to identify their training background (neurology-, neurosurgery-, or radiology-trained endovascular specialist, vascular neurologist or neurointensivist). Reasons for intubation and agreement between clinicians for each case were ascertained. RESULTS: The decision to intubate the patient was made in 63 of 200 total clinical scenarios. The major reasons identified by the physicians for preprocedural intubation were high National Institute of Health stroke scale scores on admission 26.9% (n = 17), labored breathing or desaturation 23.8% (n = 15), less than optimal respiratory status of patients combined with drowsiness or reduced level of consciousness 14.3% (n = 9), inability to follow command due to aphasia 12.7% (n = 8), seizures 1.6% ( n = 1), and no reason 20.6% (n = 13). Overall agreement between clinicians regarding decision of preprocedural intubation among the 10 case scenarios was 30.1% (standard error [SE] 2.3%). The agreement between neurosurgeons was 37.5% (SE = 31.6), interventional neurologist 19.8% (SE = 4.7), and vascular neurologist/neurointensivist 39.3% (SE = 5.9). CONCLUSION: The decision of preprocedural intubation varies widely among clinicians. Because of recent data that suggests that decision of preprocedural intubation may impact on patients' outcomes, better standardization of such practices is required.

Thrombolytic treatment for in-hospital ischemic strokes in United States.

BACKGROUND: Despite the recent emphasis on protocols for emergent triage and treatment of in-hospital acute ischemic stroke, there is little data on outcomes of patients receiving thrombolytics for in-hospital ischemic strokes. The objective of this study was to determine the rates of patients with in-hospital ischemic stroke treated with thrombolytics and to compare outcomes with patients treated on admission. METHODS: We analyzed an 8-year data (2002-2010) from the National Inpatient Survey. We identified patients who had in-hospital ischemic strokes (thrombolytic treatment after 1 day of hospitalization) and those treated on admission day. We compared demographics, clinical characteristics, in hospital complications and procedures, length of stay, hospitalization charges, and discharge disposition between the two groups. RESULTS: A total of 25193 (19%) and 109784 (81%) patients received thrombolytics for in-hospital and on admission acute strokes, respectively. In-hospital complications including intracerebral hemorrhage, pneumonia, deep venous thrombosis, pulmonary embolism and sepsis and in-hospital procedures such as cerebral angiography, endovascular thrombectomy, carotid artery stent placement, carotid endarterectomy, intubation, mechanical ventilation, gastrostomy, transfusion of blood products were significantly higher in the in-hospital stroke group. In a multivariate analysis, those who were treated following in-hospital stroke had higher rates of in-hospital mortality (odds ratio (OR) 1.1, 95% confidence interval (CI) 1.0-1.3, p = 0.05), and post-thrombolytic ICH (OR 1.2, CI 1.0-1.3, p = 0.03). CONCLUSION: One out of every five acute ischemic stroke patients treated with thrombolytics is receiving the treatment for in-hospital stroke. The higher mortality and complicated hospitalization in such patients needs to be recognized.

Late onset multiple sclerosis: Is it really late onset?

BACKGROUND: Multiple sclerosis (MS) is the most common demyelinating disease, and onset over the age of 50 years is referred to as late onset MS (LOMS). It has been thought that LOMS patients will be more likely to exhibit a primary progressive (PPMS) clinical course. OBJECTIVE: To identify the clinical characteristics of demyelinating disease in patients over the age of 50 years from four different MS centers in the Northern Midwest USA. METHODS: We reviewed medical records of all patients seen at the MS centers and identified those who were 50 years of age or more at the time of first spontaneously reported symptoms. We included those who were diagnosed with MS or clinically isolated syndrome (CIS) and excluded MS mimickers. Demographics, initial clinical course diagnosis, clinical characteristics, and any available five-year follow up data were collected. The clinical course was reevaluated in each patient with careful questioning regarding any prior focal neurological symptoms that had persisted for at least 48h, not otherwise explained. Those with a prior event who were initially diagnosed with PPMS or CIS were reclassified as secondary-progressive MS (SPMS) and relapsing-remitting MS (RRMS) respectively. RESULTS: We identified 124 patients from a total of 3700 patients, making LOMS 3.4% MS in our population. The initial clinical course was RRMS in 50 (40%), PPMS in 44 (36%), SPMS in 15 (12%), and CIS in 15 (12%) patients. After reclassification the clinical course was RRMS in 55 (44%), PPMS in 25 (20%), SPMS in 34 (28%), and CIS in 10 (8%) patients. The clinical syndrome was identified as acute for 77 patients (62%) with transverse myelitis (N=25, 32%) as the most common type. The clinical syndrome was chronic for 47 patients (37%) and again transverse myelitis (N=24, 51%) was the most common type. Five-year follow up data was available for 44% of these patients. DISCUSSION: LOMS is rare and RRMS is the most common clinical course. Reclassification of the clinical course, not done before in any other LOMS study, with careful questioning regarding a prior neurological event reveals that SPMS is the most common type of progressive MS and PPMS may be less common than previously thought. Transverse myelitis is the most common clinical presentation.

Intracerebral hemorrhage: a review of coagulation function.

Intracerebral hemorrhage (ICH) is associated with a higher mortality rate among stroke subtypes. The amount of hematoma at baseline and subsequent expansion are considered strong independent markers for determining poor clinical outcome. Even though reduction in blood pressure to prevent and control the amount of bleeding in ICH has received considerable amount of attention, the impact of coagulopathy and platelet dysfunction, on the bleeding diathesis has not been extensively investigated. With the increasing use of antiplatelets and/or anticoagulants, given the aging population, a deeper understanding of the interactions between ICH and hemostatic mechanisms is essential to help minimize the risk of a catastrophic coagulopathy-related ICH. In this review article, etiology and risk factors associated with coagulopathy-related ICH are discussed. An overview of coagulation abnormalities, hemostatic agents, and blood biomarkers pertaining to ICH is included.

Therapeutic hypothermia in stroke and traumatic brain injury.

Therapeutic hypothermia (TH) is considered to improve survival with favorable neurological outcome in the case of global cerebral ischemia after cardiac arrest and perinatal asphyxia. The efficacy of hypothermia in acute ischemic stroke (AIS) and traumatic brain injury (TBI), however, is not well studied. Induction of TH typically requires a multimodal approach, including the use of both pharmacological agents and physical techniques. To date, clinical outcomes for patients with either AIS or TBI who received TH have yielded conflicting results; thus, no adequate therapeutic consensus has been reached. Nevertheless, it seems that by determining optimal TH parameters and also appropriate applications, cooling therapy still has the potential to become a valuable neuroprotective intervention. Among the various methods for hypothermia induction, intravascular cooling (IVC) may have the most promise in the awake patient in terms of clinical outcomes. Currently, the IVC method has the capability of more rapid target temperature attainment and more precise control of temperature. However, this technique requires expertise in endovascular surgery that can preclude its application in the field and/or in most emergency settings. It is very likely that combining neuroprotective strategies will yield better outcomes than utilizing a single approach.

Indications and applications for extracranial carotid artery stent placement.

Treatment of high-grade symptomatic carotid stenosis via carotid endarterectomy has been shown to be superior to medical management alone in several studies. Carotid angioplasty and stenting (CAS) has emerged as an alternative approach to endarterectomy to reduce the associated perioperative risks. Several anatomic and physiologic factors that increase the risk of stroke and/or death associated with endarterectomy have been identified. The alternative approach of CAS has been found to be noninferior to endarterectomy for high surgical risk patients with severe symptomatic carotid stenosis and the use of this procedure is supported by the current widely accepted guidelines. In patients with standard surgical risk, the differential benefit of CAS compared with endarterectomy is not clear. Several advantages of CAS have been identified in previous studies in selected patients. The results of CAS will undoubtedly continue to improve with advances in device designs, technological expertise, and appropriate patient selection.