Long-term mortality, disability and stroke recurrence in patients with basilar artery occlusion.

BACKGROUND AND PURPOSE: The long-term outcomes and stroke recurrence after basilar artery occlusion (BAO) are largely unknown. We aimed to assess these variables in a comparatively large series of consecutive patients. METHODS: Adults with acute BAO were retrospectively identified from 1976 to 2011. Post-discharge records were reviewed to assess for stroke recurrences, mortality and disability. Exploratory analysis of survival was carried out using Kaplan-Meier and log-rank tests. Factors associated with survival time were determined using Cox models. RESULTS: A total of 86 patients (34% female, median age 72 [interquartile range (IQR), 60-79] years) with a median National Institutes of Health Stroke Scale score of 11 (IQR, 6-27) were included. Twenty-nine patients (34%) died during the initial hospitalization. Median modified Rankin Scale (mRS) score at discharge among survivors was 4 (IQR, 2.5-5.5). At 1 and 5 years, 70% of survivors ad a mRS ≤3. Seventeen patients had recurrent strokes during the hospitalization and 12 patients had 19 recurrent strokes after discharge. The median survival time was 52 days (IQR, 6-1846). Older age per decade on admission [adjusted hazard ratios (aHR), 1.32; 95% confidence interval (CI), 1.05-1.66, P = 0.02] and a higher mRS at discharge (aHR, 4.48; 95% CI, 2.72-7.39, P < 0.0001) were associated with mortality. Patients who were not treated with any reperfusion therapy had a trend towards reduced mortality (aHR, 0.39; 95% CI, 0.14-1.08, P = 0.07). CONCLUSIONS: Survivors from BAO had severe short-term functional disability. Most deaths and stroke recurrences occurred within the first year following the initial event. The risk of death was higher in older and more disabled survivors. However, favorable long-term recovery was possible.

Quantitative Modeling of External Ventricular Drain Output to Predict Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage: Cohort Study.

BACKGROUND: Acute hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH); however, attempts to predict shunt-dependent chronic hydrocephalus using clinical parameters have been equivocal. METHODS: Cohort study of aSAH is treated with external ventricular drainage (EVD) placement at our institution, 2001-2016, via logistic regression. EVD-related parameters included mean/total EVD output (days 0-2), EVD days, EVD days ≤ 5 mmHg, and wean/clamp fails. aSAH outcomes assessed included ventriculoperitoneal shunt (VPS) placement, delayed cerebral ischemia (DCI), radiographic infarction (RI), symptomatic vasospasm (SV), age, and aSAH grades. RESULTS: Two hundred and ten aSAH patients underwent EVD treatment for a median 12 days (range 1-54); 85 required VPS (40%). On univariate analysis, EVD output, total EVD days, EVD days ≤ 5 mmHg, and wean/clamp trial failures were significantly associated with VPS placement (p < 0.01 for all parameters). No EVD output parameter demonstrated a significant association with DCI, RI, or SV. On multivariate analysis, EVD output was a significant predictor of VPS placement, after adjusting for age and clinical and radiological grades; the optimal threshold for predicting VPS placement was mean daily output > 204 ml on days 0-2 (OR 2.59, 95% CI 1.31-5.07). Multiple wean failures were associated with unfavorable functional outcome, after adjusting for age, grade, and VPS placement (OR 1.65, 95% CI 1.10-2.47). We developed a score incorporating age, grade and EVD parameters (MAGE) for predicting VPS placement after aSAH. CONCLUSIONS: EVD output parameters and wean/clamp trial failures predicted shunt dependence in an age- and grade-adjusted multivariable model. Early VPS placement may be warranted in patients with MAGE score ≥ 4, particularly following 2 failed wean trials.

Distinguishing clinical and radiological features of non-traumatic convexal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The full spectrum of causes of convexal subarachnoid hemorrhage (cSAH) requires further investigation. Therefore, our objective was to describe the spectrum of clinical and imaging features of patients with non-traumatic cSAH. METHODS: A retrospective observational study of consecutive patients with non-traumatic cSAH was performed at a tertiary referral center. The underlying cause of cSAH was characterized and clinical and imaging features that predict a specific etiology were identified. The frequency of future cSAH or intracerebral hemorrhage (ICH) was determined. RESULTS: In all, 88 patients [median age 64 years (range 25-85)] with non-traumatic cSAH were identified. The most common causes were reversible cerebral vasoconstriction syndrome (RCVS) (26, 29.5%), cerebral amyloid angiopathy (CAA) (23, 26.1%), indeterminate (14, 15.9%) and endocarditis (9, 10.2%). CAA patients commonly presented at an older age than RCVS patients (75 years versus 51 years, P < 0.0001). Thirteen patients (14.7%) had recurrent cSAH, and 12 patients (13.6%) had a subsequent ICH. However, the risk was high amongst those with CAA compared to those caused by RCVS, with recurrent cSAH in 39.1% and subsequent lobar ICH in 43.5% of CAA cases. CONCLUSIONS: Our study demonstrates the clinical diversity of cSAH. Older age, sensorimotor dysfunction and stereotyped spells suggest CAA as the underlying cause. Younger age and thunderclap headache predict RCVS. Yet, various other causes also need to be considered in the differential diagnosis.

Hemorrhage or Ischemia? The Importance of 'Spotting' it Right.

BACKGROUND: A 78-year-old woman was transferred directly to an ICU because of intracerebral hemorrhage. However, on careful review of the initial imaging, the likely diagnosis was ischemic stroke and reperfusion hemorrhage. METHODS: Case report was explained. RESULTS: The patient suffered significant reperfusion hemorrhage. A CT angiogram revealed contrast extravasation "spot sign" in the bed of the expanding hemorrhage and an occlusive thromboembolism distal to the initial ischemic insult. CONCLUSION: In this case of embolic ischemic stroke with reperfusion hemorrhage, contrast extravasation "spot sign" was associated with hematoma expansion.

Central pontine and extrapontine myelinolysis: a systematic review.

The purpose was to perform a systematic review of studies on central pontine and extrapontine myelinolysis [forms of osmotic demyelination syndrome (ODS)] and define the spectrum of causes, risk factors, clinical and radiological presentations, and functional outcomes of this disorder. A thorough search of the literature was conducted using multiple databases (PubMed, Ovid Medline and Google) and bibliographies of key articles to identify all case series of adult patients with ODS published from 1959 to January 2013. Only series with five or more cases published in English were considered. Of the 2602 articles identified, 38 case series were included comprising a total of 541 patients who fulfilled our inclusion criteria. The most common predisposing factor was hyponatremia (78%) and the most common presentation was encephalopathy (39%). Favorable recovery occurred in 51.9% of patients and death in 24.8%. Liver transplant patients with ODS had a combined rate of death and disability of 77.4%, compared with 44.7% in those without liver transplantation (P < 0.001). ODS is found to have a good recovery in more than half of cases and its mortality has decreased with each passing decade. Favorable prognosis is possible in patients of ODS, even with severe neurological presentation. Further research is required to confirm the differences found in liver transplant recipients.

Outcome of fulminant bacterial meningitis in adult patients.

BACKGROUND AND PURPOSE: The objective of our study was to identify neurological factors associated with poor outcome in adult patients with fulminant bacterial meningitis. METHODS: This was a retrospective review of consecutive adult patients with fulminant bacterial meningitis, defined as meningitis causing coma within 24-48 h of hospitalization, at Mayo Clinic Rochester between January 2000 and November 2010. Functional status was assessed at discharge and upon last follow-up using the modified Rankin scale (mRS). The primary end-point was death or new major disability (increase of >2 on the mRS) at last follow-up. RESULTS: Thirty-nine patients were identified. Encephalopathy (44%), coma (28%), focal seizures (3%) or a combination of these (26%) were present on admission. The most common pathogen was Streptococcus pneumoniae (57%). All patients were treated with broad spectrum antibiotics and 51% received steroids. Serious systemic complications were seen in 23 patients. Sixteen patients (41%) died during hospitalization. Median mRS at hospital discharge for surviving patients was 3; four patients had new major disability with a mean follow-up of 11 months. Predictors of death or new major disability included lower Glasgow Coma Scale score at nadir [P = 0.002; age- and sex-adjusted odds ratio (OR) 0.46, 95% confidence interval (CI) 0.28-0.48], longer duration of symptoms before hospitalization (P = 0.045; adjusted OR 2.34, 95% CI 1.02-5.37), abnormal head imaging at presentation (P = 0.008; adjusted OR 9.40, 95% CI 1.78-49.6) and use of intracranial pressure monitoring (P = 0.010, adjusted OR 51.0, 95% CI 2.51-1036). CONCLUSION: Many adult patients who survive hospitalization are able to regain their pre-morbid level of function. Aggressive management of bacterial meningitis is justified even in comatose adult patients.

Mortality in cerebral venous thrombosis: results from the national inpatient sample database.

BACKGROUND: Outcomes of cerebral venous thrombosis (CVT) vary from full recovery to death. Few studies have been performed examining epidemiologic and medical risk factors associated with high mortality in CVT. In this study, we examined the National Inpatient Sample (NIS) to determine the epidemiologic and medical risk factors associated with increased mortality from CVT. MATERIALS AND METHODS: Using the NIS from 2001 to 2008, patients who suffered from CVT were identified using the ICD-9 codes 437.6 (nonpyogenic thrombosis of intracranial venous sinus), 325 (phlebitis and thrombophlebitis of intracranial venous sinuses) and 671.5 (peripartum phlebitis and thrombosis, cerebral venous thrombosis, thrombosis of intracranial venous sinus). We analyzed the associations of demographic factors, risk factors, comorbidities, complications of CVT, and therapeutic interventions with in-hospital mortality. We performed a multivariate logistic regression analysis to determine which variables were independently associated with in-hospital mortality. RESULTS: 11,400 patients were hospitalized with CVT between 2001 and 2008. Two-hundred and thirty-two (2.0%) suffered in-hospital mortality. Patients 15-49 years old had the lowest mortality rate (1.5%) compared with 2.8% for patients aged 50-64 (p < 0.001) and 6.1% for patients ≥65 years old (p < 0.001). The most common condition associated with CVT was pregnancy/puerperium (24.6%), and these women had a low mortality rate (0.4%). On multivariate analysis, the comorbidity most strongly associated with increased risk of mortality was sepsis (mortality rate 15.6%, OR = 7.5, 95% CI = 4.79-11.53, p < 0.001). Malignancy, underlying autoimmune disease and substance abuse were also independently associated with mortality, but with lower mortality rates (<5%). Complications associated with increased risk of mortality included paralysis (8.0%, OR = 3.4, 95% CI = 3.17-6.96, p < 0.001), intracranial hemorrhage (8.7%, OR = 5.4, 95% CI = 4.38-7.96, p < 0.001), and hydrocephalus (15.0%, OR = 3.2, 95% CI = 5.54-15.11, p = 0.004). Demographic variables associated with decreased mortality on multivariate analysis were male gender (2.1%, OR = 0.62, 95% CI = 0.43-0.87, p = 0.006) and Asian/Pacific Islander race (OR = 0.00, 95% CI = 0-0.27, p < 001). CONCLUSIONS: CVT is associated with a low in-hospital mortality rate. Amongst patients suffering CVT, male gender and Asian/Pacific Islander race were independently associated with lower odds of in-hospital mortality when compared to their female and white counterparts, respectively. Septic patients with CVT have the greatest risk of in-hospital mortality. Hydrocephalus, intracranial hemorrhage, and motor deficits are also associated with higher risk of death. Our results build on previous evidence that serves to define a group of patients with CVT at high risk of early death.

Is early DNR a self-fulfilling prophecy for patients with spontaneous intracerebral hemorrhage?

BACKGROUND: To investigate differences in outcome of patients with intracerebral hemorrhage (ICH) based on institution of do-not-resuscitate (DNR) order within first 24 h of admission. METHODS: A prospective registry of patients presenting with ICH from Jan 2006 to Dec 2008 was created. Patients with and without DNR orders instituted within 24 h of admission were classified as cases and controls respectively and were matched based on age and stroke severity. Demographics, intracerebral volume of hematoma, intraventricular extension of hemorrhage (IVH), invasive treatments, and outcomes at discharge were collected. All patients were followed up at least for 1 year, to determine mortality outcomes. RESULTS: Of a total of 245 subjects, 18 % had DNR order instituted within 24 h of admission. After matching, a total of 69 controls were available for 44 cases. There was no difference in demographics, IVH extension, volume of hemorrhage, and length of stay among cases and controls. Higher proportions of controls had surgical evacuation of the hematoma (p = 0.0125) and mechanical ventilation (p = 0.0001). There was no significant difference in functional outcome and survival rates among cases and controls at the end of 1 week, 1 month, and 1 year. CONCLUSIONS: DNR institution and restriction of resuscitation was not associated with poor outcome or difference in survival within 1 year after ICH. This indicates an early DNR probably does not lead to a self-fulfilling prophecy in this population, and might be explained by our practice, were DNR orders do not impact the level of supportive medical care we provide.

Usefulness of pulmonary function tests and blood gases in acute neuromuscular respiratory failure.

BACKGROUND AND PURPOSE: Define the usefulness of pulmonary function tests (PFT) and arterial blood gases (ABG) in patients admitted to the ICU with acute neuromuscular respiratory failure (NMRF). METHODS: We reviewed 76 patients admitted to an ICU at Mayo Clinic (Rochester) between 2003 and 2009 with acute NMRF defined as need for mechanical ventilation (MV) because of primary impairment of the peripheral nervous system. Poor functional outcome was defined as a modified Rankin score >3. RESULTS: Median age was 65years. The most frequent diagnosis was myasthenia gravis (25 patients); 54% of patients had no known neuromuscular diagnosis before admission, and 11% had no specific diagnosis at discharge. Median MV time was 16days; 14% of patients died during hospitalization, and 63% were severely disabled at discharge. Maximal expiratory pressure ≤30cm H(2) O and maximal inspiratory pressure (MIP) worse than -28cm H2 O before MV were associated with need for invasive MV for longer than 7days (P=0.02). Indicators of chronic respiratory acidosis (low pH, high pCO2 , and high HCO3 ) before MV were associated with in-hospital death and poor functional outcome, but mostly in patients with progressive, untreatable neuromuscular diagnoses. CONCLUSIONS: In patients with primary acute NMRF, bedside PFT and ABG before MV can be used to predict evolution and outcome. Lower MIP and MEP portend prolonged MV and are more useful than forced vital capacity. Presentation with chronic respiratory acidosis is associated with high risk of in-hospital mortality and severe disability, especially in patients without treatable diagnoses.

Wolf in sheep's clothing: acute chloroma disguised as a subdural hematoma.

BACKGROUND: Subdural hematomas are not infrequent among patients with hematologic disorders as they are prone to thrombocytopenia from their disease and chemotherapy. However, rarely these patients can also have leukemic involvement of the subdural space. METHODS: Case Report with CT scan and intraoperative photographs. RESULTS: A 45-year-old woman with acute myeloid leukemia presented with progressive headache, somnolence, and hemiparesis. She was noted to be thrombocytopenic. CT scan revealed a heterodense extra-axial lesion consistent with an acute to subacute subdural hematoma. There was no antecedent trauma. After platelet transfusion, she was taken for burr hole evacuation and an opalescent pearly white mass was encountered. Pathology revealed myeloid sarcoma. CONCLUSIONS: Myeloid sarcoma can mimic subdural hematoma both clinically and radiologically. It should be considered when a patient with a prior leukemia and no antecedent trauma presents with an extra-axial lesion.

Disparities in the Use of Mechanical Thrombectomy Alone Compared with Adjunctive Intravenous Thrombolysis in Acute Ischemic Stroke in the United States.

BACKGROUND AND PURPOSE: For patients with large-vessel occlusion, mechanical thrombectomy (MT) without IV-tPA is a proved strategy. The relative benefit of direct MT versus MT+IV-tPA for patients with indications for IV-tPA is being actively investigated. We used a national inpatient database to assess trends in use and patient profiles after MT+IV-tPA versus mechanical thrombectomy alone. MATERIALS AND METHODS: The National Inpatient Sample was queried between 2013 and 2018 for patients undergoing mechanical thrombectomy for acute ischemic stroke. Patients who received mechanical thrombectomy alone were compared with those who underwent MT+IV-tPA. The Cochran-Armitage test was conducted to assess the linear trend of use of mechanical thrombectomy alone among the entire cohort and between admissions involving non-White and White patients. All estimates were nationalized using discharge weights. RESULTS: A total of 89,645 weighted admissions were identified pertaining to mechanical thrombectomy for acute ischemic stroke from 2013 to 2018. Of these, 59,935 (66.9%) admissions involved mechanical thrombectomy alone. There was an increase in the trend toward the use of mechanical thrombectomy alone (trend: 3.26%; P < .001) per year. Multivariable regression analysis regarding patient profiles indicated that patients who identified as Black (OR = 0.83, P = .001) or Hispanic (OR = 0.79; P < .001) were more likely to undergo mechanical thrombectomy alone compared with those who identified as White. There was no statistically significant difference in the slope between non-White and White populations receiving mechanical thrombectomy alone (trend: +0.93% in favor of non-White; P = .096). CONCLUSIONS: Our results indicated that mechanical thrombectomy alone was used more frequently than MT+IV-tPA among patients with acute ischemic stroke. The disparity between those who identify as White and non-White persisted across the years, though it is closing.

Carotid Intraplaque Hemorrhage and Stenosis: At What Stage of Plaque Progression Does Intraplaque Hemorrhage Occur, and When is It Most Likely to Be Associated with Symptoms?

BACKGROUND AND PURPOSE: The relationship between carotid intraplaque hemorrhage and luminal stenosis severity is not well-established. We sought to determine whether intraplaque hemorrhage is related to carotid stenosis and at what degree of stenosis intraplaque hemorrhage most likely contributes to ischemic symptoms. MATERIALS AND METHODS: Consecutive patients who underwent MR carotid plaque imaging with MPRAGE sequences to identify intraplaque hemorrhage were retrospectively reviewed. Degrees of stenoses were categorized as minimal (<30%), moderate (30%-69%), and severe (>70%). Arteries were categorized into 2 groups: symptomatic (ipsilateral to a cerebral ischemic event) and asymptomatic (from a patient without an ischemic event). Multiple regression analyses were used to determine independent associations between the degree of stenosis and intraplaque hemorrhage and the presence of intraplaque hemorrhage with symptoms among categories of stenosis. RESULTS: We included 449 patients with 449 carotid arteries: Two hundred twenty-five (50.1%) were symptomatic, and 224 (49.9%) were asymptomatic. An increasing degree of stenosis was independently associated with the presence of intraplaque hemorrhage (OR = 1.02; 95% confidence interval, 1.01-1.03). Intraplaque hemorrhage was independently associated with ischemic events in arteries with <30% stenosis (OR = 5.68; 95% CI, 1.49-21.69). No such association was observed in arteries with >30% stenosis. Of symptomatic arteries with minimal stenosis, 8.7% had intraplaque hemorrhage versus 1.7% of asymptomatic arteries (P = .02). No differences in intraplaque hemorrhage prevalence were found between symptomatic and asymptomatic groups with moderate (P = .18) and severe stenoses (P = .99). CONCLUSIONS: The presence of intraplaque hemorrhage on high-resolution plaque imaging is likely most useful in identifying symptomatic plaques in cases of minimal stenosis.

Neurological complications following adult lung transplantation.

The full spectrum of neurologic complications and their impact on survival in lung recipients has not been reported. A retrospective cohort review of the Mayo Clinic Lung Transplant Registry (1988-2008) was performed to determine the range of neurologic complications in a cohort of adult lung recipients. Cox regression models were used to assess risk factors for neurological complications and death posttransplant. One hundred and twenty lung transplant recipients (53% women, median age at transplantation 53 years, range 21-73, median survival 4.8 years) were identified, of whom 95 had a neurological complication posttransplantation (median time to complication 0.8 years). Neurological complications were severe in 46 patients (requiring hospitalization or urgent care and evaluation) and were most often perioperative stroke or encephalopathy. Age predicted neurological complications of any type, whereas lung allocation score, bilateral lung transplantation, sex, underlying lung disease, elevated hemoglobin A1C, renal insufficiency and smoking history did not. Neurological complications of any severity (HR 4.3, 95% CI 2.2-8.6, p < 0.001) and high severity (HR 7.2, 95% CI 3.5-14.6, p < 0.001) were associated with increased risk of death. Neurological complications are common after lung transplantation, affecting 92% of recipients within 10 years. Severe neurologic complications are also common, affecting 53% of recipients within 10 years.

Location-Specific ASPECTS Paradigm in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

BACKGROUND: Weighting neuroimaging findings based on eloquence can improve the predictive value of ASPECTS, possibly aiding in informed treatment decisions for acute ischemic stroke. PURPOSE: Our aim was to study the contribution of region-specific ASPECTS infarction to acute ischemic stroke outcomes. DATA SOURCES: We searched MEDLINE and EMBASE for reports on ASPECTS in patients with acute ischemic stroke from 2000 to March 2019. STUDY SELECTION: Two investigators independently reviewed articles and extracted data. Three-month poor functional outcome defined as mRS >2 was the primary end point. DATA ANALYSIS: A random-effects meta-analysis was performed to compare the association between infarct and mRS >2 among ASPECTS regions. Subanalyses included the following: laterality of stroke (left/right), imaging technique (NCCT or advanced imaging with DWI, CTP, or CTA), and interventional technique (IV-tPA/conservative management or mechanical thrombectomy). DATA SYNTHESIS: M6 infarct was most associated with poor functional outcome (OR = 3.26; 95% CI, 2.21-4.80; P < .001). Pair-wise comparisons of ASPECTS regions regarding the association between infarct and mRS >2 were not significant, with the exception of M6 versus lentiform (P = .009). However, pair-wise comparisons among ASPECTS regions were not significant among subgroup analyses. LIMITATIONS: Limitations were the heterogeneity of time points, neuroimaging modalities, and interventional techniques; limited studies for inclusion; publication bias among some comparisons; and the retrospective nature of included studies. CONCLUSIONS: Our study indicated an unequal impact of some ASPECTS subregions in predicting outcomes of patients with acute ischemic stroke. Stroke laterality, imaging technique, and interventional technique subgroup analyses showed no differences among ASPECTS regions in predicting outcome. Investigation in larger cohorts is required to assess the association of ASPECTS with acute ischemic stroke outcome.

Clinical Outcomes of Patients with Delayed Diagnosis of Spinal Dural Arteriovenous Fistulas.

BACKGROUND AND PURPOSE: Spinal dural arteriovenous fistulas are commonly missed on imaging or misdiagnosed as inflammatory or neoplastic processes. We reviewed a consecutive series of spinal dural arteriovenous fistulas referred to our institution that were missed or misdiagnosed on initial imaging and studied the clinical consequences of missing or misdiagnosing the lesion. MATERIALS AND METHODS: We reviewed spinal dural arteriovenous fistulas diagnosed at our institution between January 1, 2000, and November 1, 2014. A lesion was defined as "misdiagnosed" if initial MR imaging or CT myelography demonstrated characteristic imaging features of spinal dural arteriovenous fistula but the patient was clinically or radiologically misdiagnosed. Outcomes included length of delay of diagnosis, increased disability (increase in mRS or Aminoff motor disability of ≥1 point) between initial imaging evaluation and diagnosis date, and posttreatment disability. RESULTS: Fifty-three consecutive spinal dural arteriovenous fistulas that were initially misdiagnosed despite having characteristic imaging findings on MR imaging or CT myelography were included in our study. Eight patients (18.9%) underwent spinal angiography before referral, which was interpreted as having negative findings but was either incomplete (6 cases) or retrospectively demonstrated the spinal dural arteriovenous fistulas (2 cases). The median time of delayed diagnosis was 6 months (interquartile range, 2-14 months). Fifty-one patients (96.2%) had increased disability between the initial study, which demonstrated features of a spinal dural arteriovenous fistula, and diagnosis. Thirty-two patients (60.4%) developed a new requirement for a walker or wheelchair. Following treatment, 21 patients (41.2%) had an improvement of 1 point on the mRS or Aminoff motor disability scale. CONCLUSIONS: Delayed diagnosis of spinal dural arteriovenous fistula with characteristic imaging features results in high rates of additional disability that are often irreversible despite surgical or endovascular treatment of the fistula.

Surgical treatment of nonbacterial thrombotic endocarditis presenting with stroke.

BACKGROUND: Necropsy studies have shown that nonbacterial thrombotic endocarditis (NBTE) may be associated with cerebral infarctions and antemortem diagnosis is now possible. However, the best treatment for patients with NBTE presenting with stroke is not known. We describe three patients presenting with an acute embolic stroke secondary to large,mobile vegetations detected by transthoracic (one case) or transesophageal echocardiography (two cases). All patients underwent surgery for removal of the vegetations to prevent recurrent embolic events; valve replacement was necessary in two cases. The sterile nature of the vegetations was confirmed by pathological examination and negative stains and cultures of the surgical samples. A previously unrecognized hypercoagulable condition was diagnosed in all patients (antiphospholipid antibody syndrome in two cases and disseminated adenocarcinoma in one case). CONCLUSION: NBTE should be considered among the possible causes of embolic stroke even in the absence of history of cancer, hypercoagulability, or previous embolic manifestations. If NBTE is diagnosed, the possibility of underlying thrombophilia should be thoroughly investigated. Valvular surgery represents a valuable therapeutic alternative in patients with large mobile vegetations, valvular dysfunction or recurrent embolic events despite anticoagulation.

Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types. MATERIALS AND METHODS: In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization. RESULTS: Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87-3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36-3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35-0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37-0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score. CONCLUSIONS: Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.

Non-recognition of depression and other non-motor symptoms in Parkinson's disease.

BACKGROUND: Depression, anxiety, fatigue and sleep disorders occur commonly in patients with Parkinson's disease (PD). These non-motor symptoms often contribute to the reduction of functional abilities in PD patients. OBJECTIVE: This study was designed to evaluate the diagnostic accuracy of the treating neurologist for a variety of behavioral symptoms commonly associated with PD. METHODS: A prospective evaluation of 101 patients with PD selected in no particular order was conducted. All patients were evaluated with the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn & Yahr Stage (H/Y), and the Schwab & England Scale (S/E). The patients completed a brief screening questionnaire for depression and anxiety followed by the administration of a battery of standardized tests including the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Fatigue Severity Scale (FSS), and the Pittsburgh Sleep Quality Inventory (PSQI). RESULTS: Standardized testing showed evidence of a problem with depression in 44% of patients, anxiety in 39%, fatigue in 42% and sleep disturbance in 43%. The prevalence of these conditions, identified by the treating neurologist was lower: 21% with depression, 19% with anxiety, 14% with fatigue and 39% with sleep disturbance. The diagnostic accuracy for the treating neurologists was 35% for depression, 42% for anxiety, 25% for fatigue, and 60% for sleep disturbance. CONCLUSION: This study demonstrates that during routine office visits, neurologists failed to identify the presence of depression, anxiety, and fatigue more than half of the time and failed to recognize sleep disturbance in 40% of patients. Awareness of the likelihood of underrecognition of behavioral symptoms in PD should generate approaches to improve diagnostic accuracy and facilitate timely therapeutic interventions.

Socioeconomic disparities in the utilization of mechanical thrombectomy for acute ischemic stroke in US hospitals.

BACKGROUND AND PURPOSE: Previous studies have demonstrated that socioeconomic disparities in the treatment of cerebrovascular diseases exist. We studied a large administrative data base to study disparities in the utilization of mechanical thrombectomy for acute ischemic stroke. MATERIALS AND METHODS: With the utilization of the Perspective data base, we studied disparities in mechanical thrombectomy utilization between patient race and insurance status in 1) all patients presenting with acute ischemic stroke and 2) patients presenting with acute ischemic stroke at centers that performed mechanical thrombectomy. We examined utilization rates of mechanical thrombectomy by race/ethnicity (white, black, and Hispanic) and insurance status (Medicare, Medicaid, self-pay, and private). Multivariate logistic regression analysis adjusting for potential confounding variables was performed to study the association between race/insurance status and mechanical thrombectomy utilization. RESULTS: The overall mechanical thrombectomy utilization rate was 0.15% (371/249,336); utilization rate at centers that performed mechanical thrombectomy was 1.0% (371/35,376). In the sample of all patients with acute ischemic stroke, multivariate logistic regression analysis demonstrated that uninsured patients had significantly lower odds of mechanical thrombectomy utilization compared with privately insured patients (OR = 0.52, 95% CI = 0.25-0.95, P = .03), as did Medicare patients (OR = 0.53, 95% CI = 0.41-0.70, P < .0001). Blacks had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.35, 95% CI = 0.23-0.51, P < .0001). When considering only patients treated at centers performing mechanical thrombectomy, multivariate logistic regression analysis demonstrated that insurance was not associated with significant disparities in mechanical thrombectomy utilization; however, black patients had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.41, 95% CI = 0.27-0.60, P < .0001). CONCLUSIONS: Significant socioeconomic disparities exist in the utilization of mechanical thrombectomy in the United States.

Early basal ganglia hyperperfusion on CT perfusion in acute ischemic stroke: a marker of irreversible damage?

BACKGROUND AND PURPOSE: CT perfusion scans are often used in acute stroke evaluations. We aimed to assess the outcome of areas of basal ganglia hyperperfusion on CTP in patients with acute ischemic stroke. MATERIALS AND METHODS: We retrospectively reviewed the medical records and brain imaging of 139 patients presenting with acute stroke who underwent CTP for consideration of endovascular recanalization. Hyperperfusion was assessed qualitatively and defined as a matched region of increased cerebral blood flow and cerebral blood volume. CTA was used to locate arterial occlusion. Follow-up imaging was used to determine whether regions of hyperperfusion at baseline became infarcted or developed hemorrhage. Angiographic imaging was assessed to determine the presence or absence of early venous opacification. RESULTS: Six patients (4.3%) demonstrated hyperperfusion in the basal ganglia of the affected side (4 in the lenticular nucleus and 2 in the caudate). In all cases, the area of hyperperfusion ultimately proved to be infarcted. All patients had received intravenous thrombolysis before the CTP. CTA at the time of CTP showed middle or distal M1 occlusion but patency of the proximal M1 and A1 segments. Intracranial hemorrhage was noted in 2 of these 6 patients at follow-up. CONCLUSIONS: Acute basal ganglia hyperperfusion in patients with stroke may indicate nonviable parenchyma and risk of hemorrhagic conversion.