Recent Vitamin K Antagonist Use and Intracranial Hemorrhage After Endovascular Thrombectomy for Acute Ischemic Stroke.

Importance: Use of oral vitamin K antagonists (VKAs) may place patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion at increased risk of complications. Objective: To determine the association between recent use of a VKA and outcomes among patients selected to undergo EVT in clinical practice. Design, Setting, and Participants: Retrospective, observational cohort study based on the American Heart Association's Get With the Guidelines-Stroke Program between October 2015 and March 2020. From 594 participating hospitals in the US, 32 715 patients with acute ischemic stroke selected to undergo EVT within 6 hours of time last known to be well were included. Exposure: VKA use within the 7 days prior to hospital arrival. Main Outcome and Measures: The primary end point was symptomatic intracranial hemorrhage (sICH). Secondary end points included life-threatening systemic hemorrhage, another serious complication, any complications of reperfusion therapy, in-hospital mortality, and in-hospital mortality or discharge to hospice. Results: Of 32 715 patients (median age, 72 years; 50.7% female), 3087 (9.4%) had used a VKA (median international normalized ratio [INR], 1.5 [IQR, 1.2-1.9]) and 29 628 had not used a VKA prior to hospital presentation. Overall, prior VKA use was not significantly associated with an increased risk of sICH (211/3087 patients [6.8%] taking a VKA compared with 1904/29 628 patients [6.4%] not taking a VKA; adjusted odds ratio [OR], 1.12 [95% CI, 0.94-1.35]; adjusted risk difference, 0.69% [95% CI, -0.39% to 1.77%]). Among 830 patients taking a VKA with an INR greater than 1.7, sICH risk was significantly higher than in those not taking a VKA (8.3% vs 6.4%; adjusted OR, 1.88 [95% CI, 1.33-2.65]; adjusted risk difference, 4.03% [95% CI, 1.53%-6.53%]), while those with an INR of 1.7 or lower (n = 1585) had no significant difference in the risk of sICH (6.7% vs 6.4%; adjusted OR, 1.24 [95% CI, 0.87-1.76]; adjusted risk difference, 1.13% [95% CI, -0.79% to 3.04%]). Of 5 prespecified secondary end points, none showed a significant difference across VKA-exposed vs VKA-unexposed groups. Conclusions and Relevance: Among patients with acute ischemic stroke selected to receive EVT, VKA use within the preceding 7 days was not associated with a significantly increased risk of sICH overall. However, recent VKA use with a presenting INR greater than 1.7 was associated with a significantly increased risk of sICH compared with no use of anticoagulants.

Proteinuria Predicts Resistance to Antiplatelet Therapy in Ischemic Stroke.

The occurrence of a stroke while on antiplatelet agents presents a therapeutic dilemma. One of the main causes for recurrent strokes is antiplatelet resistance more commonly known as high on treatment platelet reactivity (HTPR). Prior studies have established that proteinuria is associated with HTPR following myocardial infarction. Here, we investigated whether dipstick proteinuria correlates with HTPR in patients presenting with stroke. We performed a retrospective cohort analysis of 102 patients admitted for a recurrent ischemic stroke that had either a VerifyNow aspirin or VerifyNow clopidogrel laboratory test performed to assess platelet reactivity. Dipstick proteinuria was defined as > 30 mg/dl (2+ or more). HTPR was defined as an aspirin resistance unit > 550 for aspirin and a P2Y12 reactivity unit > 208 for clopidogrel. Patients with proteinuria on dipstick were significantly more likely to have HTPR to either aspirin (p value 0.017) or clopidogrel (p value 0.017). After controlling for age, smoking, diabetes, hypertension, CAD and GFR, proteinuria was an independent predictor of HTPR for patient taking aspirin (p = 0.025). Platelet resistance is an entity that undermines the activity of antiplatelet agents in reducing stroke risk. Here, we demonstrate an association with increased platelet reactivity and proteinuria. This highlights a potential new therapeutic target in reducing future stroke risk.

Predictive value of the bispectral index for burst suppression on diagnostic electroencephalogram during drug-induced coma.

STUDY PURPOSE: To determine correlation and predictive value between data obtained with the bispectral index (BIS) and diagnostic electroencephalogram (EEG) in determining degree of burst suppression during drug-induced coma. This study seeks to answer the question: "To what degree can EEG suppression and burst count as measured by diagnostic EEG during drug-induced coma be predicted from data obtained from the BIS such as BIS value, suppression ratio (SR), and burst count?" BACKGROUND/SIGNIFICANCE: During drug-induced coma, cortical EEG is the gold standard for real-time monitoring and drug titration. Diagnostic EEG is, from setup through data analysis, labor intensive, costly, and difficult to maintain uniform clinician competency. BIS monitoring is less expensive, less labor-intensive, and easier to interpret data and establish/maintain competency. Validating BIS data versus diagnostic EEG facilitates effective brain monitoring during drug-induced coma at lower cost with similar outcomes. METHOD: This is a prospective, observational cohort study. Four consecutive patients receiving drug-induced coma/EEG monitoring were enrolled. BIS was initiated after informed consent. Variables recorded per minute included presence or absence of EEG burst suppression, burst count, BIS value over time, burst count, and SR. Pearson's product-moment and Spearman rank coefficient for BIS value and SR versus burst count were performed. Regression analysis was utilized to plot BIS values versus bursts/minute on EEG as well as SR versus burst count on EEG. EEG/BIS data were collected from digital data files and transcribed onto data sheets for corresponding time indices. RESULTS: Four patients yielded 1,972 data sets over 33 hours of EEG/BIS monitoring. Regression coefficient of 0.6673 shows robust predictive value between EEG burst count and BIS SR. Spearman rank coefficient of -0.8727 indicates strong inverse correlation between EEG burst count and BIS SR. Pearson's correlation coefficient between EEG versus BIS burst count was .8256 indicating strong positive correlation. Spearman's rank coefficient of 0.8810 and Pearson's correlation coefficient of .6819 showed strong correlation between BIS value versus EEG burst count. Number of patients (4) limits available statistics and ability to generalize results. Graphs and statistics show strong correlation/predictive value for BIS parameters to EEG suppression. CONCLUSIONS: This study is the first to measure correlation and predictive value between BIS monitoring and diagnostic EEG for degree of EEG suppression and burst count in the adult population. Available statistic tests and graphing of variables from BIS and diagnostic EEG show strong correlation and predictive value between both monitoring technologies during drug-induced coma. These support using BIS value, SR, and burst count to predict degree of EEG suppression in real time for titrating metabolic suppression therapy.

Triptan use preceding life-threatening arrhythmias in charcot-marie-tooth: a case report and review of the literature.

Charcot-Marie-Tooth (CMT) identifies a rare group of inherited disorders of the peripheral nervous system that share clinical features of sensory and motor defects, but rarely affect cardiac function. The few references that relate CMT to cardiac pathology of any sort are so rare that their finding was considered either fortuitous or suggestive of an erroneous diagnosis. The 5-HT1B/1D agonists or triptan drug class was introduced to the clinical practice arena in the early 1990s, and since then several cardiac adverse events have been associated with its use. The authors report the case of a 41-year-old white woman with CMT who had been recently prescribed sumatriptan and who presented with sudden loss of consciousness associated with ventricular fibrillation. These findings have been reported in the literature, but the association of triptan-induced arrhythmias and degenerative neuropathies remains to be established. The authors propose, through this case report and review, that the relative rarity of CMT coupled with the lack of further investigation of their association with conduction abnormalities might have set the stage for underestimation of the potentially synergistic effect with triptans in their capacity to generate life-threatening arrhythmias.

Importance of technical preparation of intraarterial shunts to prevent iatrogenic arterial injury during urgent procedures.

Although intraarterial shunting during carotid endarterectomy is a well-defined practice, its use remains controversial. Complication rates associated with shunt placement remain low, but may be underreported. When complications secondary to routine intraarterial shunting occur, they can cause significant morbidity or even mortality, emphasizing the importance of meticulous technique to prevent adverse outcomes. We report a case of internal carotid artery dissection and pseuedoaneurysm due to the technical failure of a safety device of an intraarterial shunt used during carotid endarterectomy.