Predictors and outcomes of pneumonia in patients with spontaneous intracerebral hemorrhage.

OBJECTIVES: Pneumonia is an important complication of spontaneous intracerebral hemorrhage (sICH). The purpose of this study was to determine the predictors and outcomes of the development of pneumonia in patients with sICH. METHODS: In total, 290 consecutive patients with sICH admitted within 24 hours of stroke onset were investigated in a single center, retrospective study from January 2006 to July 2009. Clinical, biochemical, and imaging variables were registered. Stroke severity and functional outcomes were evaluated with the Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS). Baseline variables that predicted pneumonia were investigated and outcomes were assessed. RESULTS: The association of our primary exposure variables, such as mechanical ventilation, tube feeding, dysphagia, and tracheostomy, with pneumonia was highly significant (P < .0001, for each variable). For mechanical ventilation, we observed an odds ratio (OR; 95% confidence interval [CI]) of 9.42 (4.24-20.9); for tube feeding, OR = 22.3 (8.91-55.8); for dysphagia, OR = 13.1 (4.66-36.7); and for tracheostomy, OR = 26.8 (8.02-89.3). After adjustment of potential confounders including GCS and mRS on admission, the use of angiotensin-converting enzyme inhibitors, proton pump inhibitors, and H2 blockers, all the adjusted OR (ORa) remained significant. For mechanical ventilation, the minimum ORa was 3.72 (95% CI: 1.68-8.26) when adjusted for GCS. For both dysphagia and tracheostomy, mRS reduced OR to 7.46 (95% CI: 3.34-10.6) in the case of dysphagia with an ORa of 16.2 (95% CI: 4.98 to 52.8) for tracheostomy. For tube feeding, both GCS and mRS reduced ORa; the former to 14.7 (95% CI: 6.16-35.0) and the latter to 15.7 (95% CI: 6.63-37.0). Pneumonia shows a significant effect on the morbidity (P = .003), length of stay (P < .0001), and mortality (P = .041) rate of the patients. CONCLUSION: Mechanical ventilation, tube feeding, dysphagia, and tracheostomy are exposures associated with increased risk of the development of pneumonia in patients with sICH. Pneumonia is associated with an increase in morbidity, length of stay, and mortality among patients with sICH.

Case Report: 84 year-old woman with alien hand syndrome.

Background: Alien hand syndrome [AHS] is a rare and ill-defined neurological disorder. It produces complex, goal-directed motion of one hand that is involuntarily instigated. This syndrome characteristically arises after brain trauma, brain surgery, stroke or encephalitis. We describe a case of AHS in a patient who had a previous episode of subarachnoid hemorrhage affecting the left frontal lobe and corpus callosum. Case presentation: An 84-year-old woman presented to the emergency department complaining of headaches and several episodes of her left arm moving as if it was groping around trying to grab at her own body. A computed tomography scan of the head demonstrated an acute left superior frontal hemorrhage with compression of the corpus callosum. Transcranial Doppler report showed no significant abnormality in the insonated vessels. After being stabilized for the acute bleed, she was treated with clonazepam 0.5 mgat night for the uncontrolled hand movements. Her movements resolved by her next month follow up. The diagnosis of AHS was made based on her clinical presentation, characterization of the movement and localization correlating with findings in neuroimaging. Conclusion: We document a rare neurologic disorder seen in patients presenting with a history of previous strokes and a typical description of involuntary and unintentional, uncontrolled unilateral arm movements with repetitive grasping. The present case has a combination of frontal and callosal lesions.  These findings appear to support a potential destruction leading to the rare syndrome.

Systematic Review and Pooled Analyses of Recent Neurointerventional Randomized Controlled Trials: Setting a New Standard of Care for Acute Ischemic Stroke Treatment after 20 Years.

BACKGROUND: Recent advances in the treatment of ischemic stroke have focused on revascularization and led to better clinical and functional outcomes. A systematic review and pooled analyses of 6 recent multicentered prospective randomized controlled trials (MPRCT) were performed to compare intravenous tissue plasminogen activator (IV tPA) and endovascular therapy (intervention) with IV tPA alone (control) for anterior circulation ischemic stroke (AIS) secondary to large vessel occlusion (LVO). OBJECTIVES: Six MPRCTs (MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME, REVASCAT and THERAPY) incorporating image-based LVO AIS were selected for assessing the following: (1) prespecified primary clinical outcomes of AIS patients in intervention and control arms: good outcomes were defined by a modified Rankin Scale score of 0-2 at 90 days; (2) secondary clinical outcomes were: (a) revascularization rates [favorable outcomes defined as modified Thrombolysis in Cerebral Infarction scale (mTICI) score of 2b/3]; (b) symptomatic intracranial hemorrhage (sICH) rates and mortality; (c) derivation of number needed to harm (NNH), number needed to treat (NNT), and relative percent difference (RPD) between intervention and control groups, and (d) random effects model to determine overall significance (forest and funnel plots). RESULTS: A total of 1,386 patients were included. Good outcomes at 90 days were seen in 46% of patients in the intervention (p < 0.00001) and in 27% of patients in the control groups (p < 0.00002). An mTICI score of 2b/3 was achieved in 70.2% of patients in the intervention arm. The sICH and mortality in the intervention arm compared with the control arm were 4.7 and 14.3% versus 7.9 and 17.8%, respectively. The NNT and NNH in the intervention and control groups were 5.3 and 9.1, respectively. Patients in the intervention arm had a 50.1% (RPD) better chance of achieving a good 90-day outcome as compared to controls. CONCLUSIONS: Endovascular therapy combined with IV tPA (in appropriately selected patients) for LVO-related AIS is superior to IV tPA alone. These results support establishing an endovascular therapy in addition to IV tPA as the standard of care for AIS secondary to LVO.

Intravenous thrombolysis in a patient using factor Xa inhibitor.

UNLABELLED: Until recently, only warfarin was approved for the prevention of stroke in patients with AF. Patients on warfarin with ischemic stroke were considered candidates for IV tPA as long as their PT/INR was not prolonged. Now, there are several new agents approved for stroke prevention in patients with non-valvular AF. The newer agents include direct thrombin inhibitors, like dabigatran, and factor Xa inhibitors, like rivaroxaban and apixaban. The coagulation profile of patients on direct thrombin inhibitors is more predictable than that of patients on factor Xa inhibitors, and the usage of IV tPA in patients on dabigatran has been previously reported. To our knowledge, there are no prior reports of IV tPA in a patient on a factor Xa inhibitor. We report a case of a 71-year-old man on rivaroxaban who improved with IV tPA after presenting with acute onset of aphasia and right-sided weakness. ABBREVIATIONS: AFAtrial fibrillationIV tPAIntravenous tissue plasminogen activatorINRInternational normalized ratioPTTPartial thromboplastin timeNIHNational Institute of HealthPTProthrombin timeCTComputed tomographyMCAMiddle cerebral arteryMRIMagnetic resonance imaging.

Reversible cerebral vasoconstriction syndrome in a 35-year-old woman following hysterectomy and bilateral salpingo-oophorectomy.

INTRODUCTION: Reversible cerebral vasoconstriction syndromes (RCVS) have been documented to take place after an inciting event or illness. They present with headache, altered mental status and focal neurologic findings. The differential diagnosis includes primary angiitis of the central nervous system (PACNS) but one major clinical difference is that the symptoms of RCVS usually resolve within days or weeks whereas PACNS is often fatal. Females of childbearing age are most commonly affected with RCVS. Cases of reversible vasculopathy have also been reported in menopausal women. The hormonal and physiologic changes that take place during the postpartum period and menopause may not be very different from those that occur after a hysterectomy and oophorectomy. METHODS: A case is presented of a 35-year-old woman who underwent a hysterectomy with bilateral salpingo-oophorectomy and then began experiencing severe headaches, visual changes and hemi-sensory loss. Physical examination, imaging and laboratory findings were descriptive of RCVS, and the patient's rapid recovery was consistent with the usual disease progression of a reversible vasculopathy. CONCLUSION: A reversible cerebral vasoconstriction syndrome may occur in some circumstances after a hysterectomy with bilateral salpingo-oophorectomy. The mechanisms involved in the development of this condition are explained by current research concerning effects on the vasculature of sudden drops in estrogens and progesterones. More studies are required to further establish the pathophysiology, diagnosis and treatment of this condition.