Simple text-messaging intervention is associated with improved door-to-needle times for acute ischemic stroke.

BACKGROUND AND PURPOSE: Timely administration of intravenous tissue-type plasminogen activator (IV tPA) is associated with improved outcomes for acute ischemic stroke; yet, developing processes to consistently provide prompt treatment remains a challenge. We developed and evaluated a simple quality improvement intervention designed to improve door-to-needle (DTN) times for resident-led Code Stroke teams at an academic medical center. METHODS: We evaluated a simple text-messaging based intervention with real-time feedback to improve DTN times for intravenous tissue-type plasminogen activator. We used the rank-sum test and linear regression to evaluate for a change in DTN times that was temporally associated with the rollout of the intervention. RESULTS: A total of 202 patients received intravenous tissue-type plasminogen activator; 94 preintervention and 108 postintervention. The median DTN time was significantly lower in the postintervention period (56 minutes [interquartile range 44-71] versus 82 minutes [IQR 68-103], P<0.0001) and a significantly higher proportion of patients were treated within 60 minutes (61% versus 16%, P<0.001). CONCLUSIONS: A simple real-time text-messaging intervention was associated with a significant improvements in DTN times for acute ischemic stroke.

Longitudinal MRI and cognitive change in healthy elderly.

Cross-sectional studies of normal aging indicate an association between memory and hippocampal volume, and between executive functioning and subcortical-frontal circuits. Much less is known, however, about the relationship between longitudinal MRI changes and cognitive decline. The authors hypothesized that longitudinal change in memory would be best predicted by change in hippocampal volumes, whereas change in executive functioning would be best predicted by cortical atrophy and progression of MRI markers of cerebrovascular disease. For this study, 50 healthy elderly subjects underwent structural MRI and cognitive testing at baseline and again at follow-up, with a mean follow-up interval of 45 months. Volumetric MRI measures were hippocampus, cortical gray matter, white matter signal hyperintensity (WMSH), and lacunae. Neuropsychological measures were psychometrically robust composite scores of episodic memory (MEM) and executive functioning (EXEC). Hierarchical multiple regression indicated that a decrease in hippocampus was associated with a decline in MEM, whereas decreased cortical gray matter and increased WMSH were independently associated with a decline in EXEC. Results suggest that in normal aging, cognitive functioning declines as cortical gray matter and hippocampus decrease, and WMSH increases. The association between WMSH and EXEC further highlights the cognitive sequealae associated with cerebrovascular disease in normal elderly.

Presentation of reversible posterior leukoencephalopathy syndrome in patients on calcineurin inhibitors.

BACKGROUND: Reversible posterior leukoencephalopathy syndrome (RPLS) is a clinico-radiologic diagnosis associated with numerous medical conditions including hypertension, immunosuppressant medications, and eclampsia. It is characterized by headache, altered mental status, seizures, visual disturbance, and neuroimaging consistent with posterior-predominant vasogenic edema. The objective of this study was to characterize the clinical spectrum and outcomes in a large series of RPLS patients, and to compare the presentation of patients taking calcineurin inhibitors (CNIs) to that of other RPLS patients. METHODS: We reviewed records of patients seen by the neurology and transplant services over an 18-year period. Comorbid conditions, medications, blood pressure, laboratory testing, clinical outcomes, and radiographic findings were collected. RESULTS: 84 episodes of RPLS were identified in 79 patients. Etiologies included CNIs (43%), hypertension (29%), renal disease (12%), preeclampsia/eclampsia (7%), and chemotherapy (5%). Patients on CNIs had lower blood pressures (p=0.002) and a lower prevalence of headache (p=0.02) compared to RPLS patients with other etiologies. Clinical recovery occurred in 65% of episodes, and radiographic resolution occurred in 67%. CONCLUSIONS: Patients with CNI-induced RPLS have lower blood pressure than other RPLS patients, but otherwise present similarly. RPLS typically occurs within days to weeks of CNI initiation in patients without elevated medication levels. Clinical and radiographic recovery occurred in the majority of patients in this series, but one-third suffered residual neurologic deficits or death. These findings highlight the importance of prompt recognition and treatment of RPLS triggers to prevent permanent sequelae.