Prevention and Correction of Dysnatremia After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Dysnatremia occurs commonly in patients with aneurysmal subarachnoid hemorrhage (aSAH). The mechanisms for development of sodium dyshomeostasis are complex, including the cerebral salt-wasting syndrome, the syndrome of inappropriate secretion of antidiuretic hormone, diabetes insipidus. Iatrogenic occurrence of altered sodium levels plays a role, as sodium homeostasis is tightly linked to fluid and volume management. METHODS: Narrative review of the literature. RESULTS: Many studies have aimed to identify factors predictive of the development of dysnatremia, but data on associations between dysnatremia and demographic and clinical variables are variable. Furthermore, although a clear relationship between serum sodium serum concentrations and outcomes has not been established-poor outcomes have been associated with both hyponatremia and hypernatremia in the immediate period following aSAH and set the basis for seeking interventions to correct dysnatremia. While sodium supplementation and mineralocorticoids are frequently administered to prevent or counter natriuresis and hyponatremia, evidence to date is insufficient to gauge the effect of such treatment on outcomes. CONCLUSIONS: In this article, we reviewed available data and provide a practical interpretation of these data as a complement to the newly issued guidelines for management of aSAH. Gaps in knowledge and future directions are discussed.

Clinical Characteristics, Imaging Findings, and Outcomes of Cerebral Air Embolism.

BACKGROUND: Arterial cerebral air embolism (CAE) is an uncommon but potentially catastrophic event. Patients can present with focal neurologic deficits, seizures, or coma. They may be treated with hyperbaric oxygen therapy. We review the causes, radiographic and clinical characteristics, and outcomes of patients with CAE. METHODS: We performed a retrospective chart review via an existing institutional database at Mayo Clinic to identify patients with arterial CAE. Demographic data, clinical characteristics, and diagnostic studies were extracted and classified on predefined criteria of diagnostic confidence, and descriptive and univariate analysis was completed. RESULTS: Fifteen patients met criteria for inclusion in our study. Most presented with focal deficits (80%) and/or coma (53%). Seven patients (47%) had seizures, including status epilepticus in one (7%). Five presented with increased muscle tone at the time of the event (33%). Computed tomography (CT) imaging was insensitive for the detection of CAE, only identifying free air in 4 of 13 who underwent this study. When obtained, magnetic resonance imaging typically showed multifocal areas of restricted diffusion. Six patients (40%) were treated with hyperbaric oxygen therapy. Age, Glasgow Coma Scale score at nadir, and use of hyperbaric oxygen therapy were not associated with functional outcome at 1 year in our cohort. Twenty-six percent of patients had a modified Rankin scale score of 0 one year after the event, and functional improvement over time was common after discharge. CONCLUSIONS: A high index of clinical suspicion is needed to identify patients with CAE because of low sensitivity of free air on CT imaging and nonspecific clinical presentation. Acute alteration of consciousness, seizures, and focal signs occur frequently. Because improvement over time is possible even among patients with severe presentation, early prognostication should be approached with caution.

Association of local anesthesia versus conscious sedation with functional outcome of acute ischemic stroke patients undergoing embolectomy.

PURPOSE: Compare functional outcomes of acute ischemic stroke patients undergoing embolectomy with either local anesthesia or conscious sedation. Secondarily, identify differences in hemodynamic parameters and complication rates between groups. MATERIALS AND METHODS: Single institution, retrospective review of all acute ischemic stroke patients undergoing embolectomy between January 2014 and July 2018 (n = 185). Patients receiving general anesthesia (n = 27) were excluded. One-hundred and eleven of 158 (70.3%) composed the local anesthesia group, and 47 (29.7%) composed the conscious sedation group. Median age was 71 years (interquartile range 59-79). Seventy-eight (49.4%) were male. The median National Institute of Health stroke scale score was 17.5 (interquartile range 11-21). Hemodynamic, medication, complication, and functional outcome data were collected from the anesthesia protocol and medical records. Good functional outcome was defined as a three-month modified Rankin Scale < 2. A multivariate analysis was performed to estimate the association of anesthesia type on three-month modified Rankin Scale score. RESULTS: Three-month modified Rankin Scale score <2 was similar between groups (p = 0.5). Patients receiving conscious sedation were on average younger than patients receiving local anesthesia (p = 0.01). Conscious sedation patients were more likely to receive intravenous thrombolytic prior to embolectomy (p = 0.025). The complication rate and hemodynamic parameters were similar between groups. CONCLUSION: Functional outcome of acute ischemic stroke patients undergoing embolectomy appears to be similar for patients receiving local anesthesia and conscious sedation. This similarity may be beneficial to a future study comparing general anesthesia to local anesthesia and conscious sedation. The use of local anesthesia or conscious sedation does not significantly impact hemodynamic status.

Real-world utilization of andexanet alfa.

OBJECTIVE: In 2018, the FDA approved andexanet alfa for the reversal of life-threatening hemorrhages in patients anticoagulated with apixaban or rivaroxaban. Yet, cost-effective factor Xa inhibitor reversal remains controversial. The objective of this study was to describe real world utilization of andexanet alfa. METHODS: This was a retrospective case series of patients receiving andexanet alfa between July 28, 2018 and April 29, 2019 at a large academic health system. Baseline demographics, anticoagulant type and reversal, as well as brain imaging were collected. Primary endpoints were stability of hematoma for intracranial hemorrhage (ICH), and hemostatic effectiveness for patients undergoing surgical procedures. Secondary endpoints were thromboembolism and 30 day mortality. RESULTS: Of the 25 patients evaluated, 13 received andexanet alfa for ICH. Eleven of the 13 had follow-up imaging available and stability was observed in 90.9%. Three patients received andexanet alfa for reversal prior to surgical procedures, and 100% hemostatic effectiveness was achieved. Nine patients received andexanet alfa for reversal of extracranial bleeding, including gastrointestinal bleed (n=4). There were no thrombotic events in our cohort, and 30 day mortality was 24%. Sixty-four percent of patients would have met exclusion criteria for the ANNEXA-4 trial. CONCLUSION: This is the largest series to date describing real-world utilization of andexanet alfa. Our series showed hemostatic efficacy in 90.9% of patients with ICH, and 100% in patients undergoing surgical procedures. There were no thrombotic complications. Yet, larger and comparative studies are needed to clarify the optimal agent and patient selection for reversal of factor Xa inhibitors.

Rethinking Prehospital Stroke Notification: Assessing Utility of Emergency Medical Services Impression and Cincinnati Prehospital Stroke Scale.

BACKGROUND AND PURPOSE: Although prehospital stroke notification has improved stroke treatment, incorporation of these systems into existing infrastructure has resulted in new challenges. The goal of our study was to design an effective prehospital notification system that allows for early and accurate identification of patients presenting with acute stroke. METHODS: We conducted a retrospective single-center cohort study of patients presenting with suspicion of acute stroke from 2014 to 2015. Data recorded included patient demographics, time of symptom onset, Cincinnati Prehospital Stroke Scale (CPSS) score, Glasgow Coma Scale score, National Institutes of Health Stroke Scale (NIHSS) score, emergency medical services (EMS) impression, acute stroke pager activation, acute intervention, and discharge diagnosis. Univariate logistic regression was performed with discharge diagnosis of stroke as the end point. RESULTS: A total of 130 patients were included in the analysis; 96 patients were discharged with a diagnosis of stroke or transient ischemic attack. Both NIHSS and the presence of face, arm and speech abnormalities on CPSS were significantly higher in patients with stroke (P < .05). EMS correctly recognized stroke in 77.1% of cases but falsely identified stroke in 85.3% of negative cases. CPSS identified 75% of acute stroke cases, but specificity was poor at only 20.6%. All patients receiving intervention had acute stroke pager activation in Emergency Department. CONCLUSIONS: Prehospital stroke notification systems utilizing EMS impressions and stroke screening tools are sensitive but lack appropriate specificity required for modern acute stroke systems of care. Better solutions must be explored so that prehospital notification can keep pace with advances in acute stroke treatment.

Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group). METHODS: A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture. RESULTS: Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66-2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22-2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48-0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29-0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67-1.06). CONCLUSIONS: Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.

Spontaneous intraventricular hemorrhage associated with prolonged diosmin therapy.

BACKGROUND: The prevalent use of anticoagulation in a growing elderly population has led to an increasing incidence of intracerebral hemorrhage. Furthermore, the understanding of the interactions and adverse effects of oral anticoagulants when used with non-FDA approved drugs is limited. Diosmin is one such non-FDA approved drug which is a semisynthetic, phlebotropic supplement with multiple microcirculatory effects. We report a case of a patient on oral anticoagulation and diosmin, who presented with spontaneous intraventricular hemorrhage, and discuss the possible etiology behind this rare event. METHODS: A retrospective chart review and a comprehensive search of the literature using the PubMed database were performed. RESULTS: A 77-year old female with a 6 week history of warfarin therapy and a several year history of diosmin use presented with severe bitemporal headache. Computed tomography scan revealed an acute hemorrhage within the right ventricle without associated intraparenchymal hemorrhage. International normalized ratio measured 1.8 and was corrected using fresh frozen plasma and vitamin K. She was discharged without neurological deficits. CONCLUSIONS: Diosmin inhibits platelet aggregation and prolongs the effect of norepinephrine on venous tone, leading to increased venoconstriction. The combined effect of chronic microcirculatory hypertension and inhibition of platelet aggregation due to diosmin may have predisposed to spontaneous hemorrhage in this anticoagulated patient. Individual cases such as this serve as a reminder that over-the-counter dietary supplements may be associated with serious adverse events. The practicing clinician should be aware of this possible adverse event when evaluating patients on oral anticoagulation and chronic diosmin treatment.

Prolonged high-dose isoflurane for refractory status epilepticus: is it safe?

Isoflurane is an alternative treatment for refractory status epilepticus. Little is known regarding human toxicities caused by isoflurane. We present 2 patients with prolonged refractory status epilepticus treated with high concentrations of isoflurane who developed signal abnormalities on magnetic resonance imaging. Patient 1 was treated with isoflurane for 85 days with 1975.2% concentration-hours. Patient 2 was treated with isoflurane for 34 days with 1382.4% concentration-hours. Serial brain magnetic resonance images in both showed progressive T2 signal hyperintensity involving thalamus and cerebellum, which improved after discontinuation of isoflurane. These cases suggest that isoflurane may be neurotoxic when used in high doses for long time periods.

Multidisciplinary management and emerging therapeutic strategies in aneurysmal subarachnoid haemorrhage.

The management of patients with aneurysmal subarachnoid haemorrhage demands expertise to anticipate, recognise, and promptly treat the many neurological and systemic complications. For this reason, these patients are best cared for in high-volume medical centres with multidisciplinary teams and should preferably be treated in a specialised intensive care unit. Endovascular occlusion and surgical clipping provide complementary alternatives for the treatment of aneurysms. Perfusion scans are redefining the way we detect delayed ischaemia as a growing body of evidence indicates that monitoring vessel diameter is insufficient to prevent cerebral infarctions. Statins, endothelin antagonists, and magnesium sulfate infusion are among the novel strategies being tested for neuroprotection and attenuation of vasospasm. The effectiveness of these treatments is supported by strong experimental data and they represent a new generation of therapeutic options developed from the understanding that vasospasm is primarily caused by endothelial dysfunction.

Minimally conscious state after ruptured giant basilar aneurysm.

OBJECTIVE: To report the clinical and radiologic findings in a case of transient minimally conscious state after rupture and coiling of a giant basilar aneurysm. DESIGN: Case report. SETTING: Neuroscience intensive care unit. PATIENT: A 44-year-old man who developed a transient minimally conscious state in association with perianeurysmal edema in the rostral brainstem and thalamus after rupture and coiling of a giant basilar artery aneurysm. MAIN OUTCOME MEASURE: Correlation of clinical and magnetic resonance imaging findings. RESULTS: A minimally conscious state and bilaterally symmetric vasogenic edema of the rostral brainstem and thalamus developed 2 days after endovascular aneurysm coiling. The clinical and radiologic abnormalities improved significantly and in parallel during the following 4 weeks. CONCLUSIONS: Perianeurysmal vasogenic edema in the brainstem and thalamus can develop after rupture and coiling of a giant basilar artery aneurysm. This process can be transient and can produce dramatic alterations in consciousness that later resolve.

Diffusion-weighted magnetic resonance imaging in symptomatic vertebrobasilar atherosclerosis and dissection.

BACKGROUND: Acute multiple brain infarction (AMBI) pattern on diffusion-weighted imaging (DWI) is associated with arterial and cardiac sources of embolism. The DWI characteristics of patients with stroke due to vertebrobasilar arterial dissection and atherosclerotic disease have not been reported in detail. OBJECTIVE: To describe the DWI stroke patterns in patients with posterior circulation occlusive disease to determine mechanisms of ischemia. DESIGN: Retrospective analysis of infarct patterns in patients with symptomatic vertebrobasilar disease. SETTING: Large community-based teaching hospital. PATIENTS: Patients admitted with stroke due to vertebrobasilar disease were identified retrospectively. Patients were included if DWI was obtained within 7 days of symptom onset. MAIN OUTCOME MEASURE: Infarct patterns were analyzed according to established templates of vascular territories. RESULTS: Eleven patients with vertebral dissection and 39 patients with atherothrombosis were identified. An AMBI pattern was present in 8 (72%) of 11 patients with arterial dissections and 25 (64%) of 39 patients with atherosclerotic disease (P = .48). Distal embolism to the terminal branches of the basilar artery occurred with equal frequency in both groups and was found in half of all cases. Isolated thalamic infarction did not occur. Pontine infarction was noted in 2 (18%) of 11 patients with dissections and 18 (46%) of 39 patients with atherosclerosis (P = .09). Cerebellar border zone involvement was found in 14 (36%) of 39 patients with atherosclerosis and 4 (37%) of 11 patients with dissections (P = .6). CONCLUSIONS: Large arterial disease is frequently associated with AMBI in the posterior circulation. The incidence of AMBI was comparable to that reported in the anterior circulation. This DWI study supports the importance of embolism as the main mechanism of infarction in patients with vertebrobasilar occlusive disease. On the basis of our experience, large-vessel vertebrobasilar disease rarely causes isolated small-vessel thalamic infarction.

Acupuncture in clinical neurology.

BACKGROUND: A majority of people in the United States use alternative or complementary therapy at some point in their lives, and acupuncture is among the most frequently used modalities. Many United States medical schools offer courses in alternative medicine, and a growing number of insurers offer coverage for alternative therapies. This paper critically reviews our current knowledge about the safety and efficacy of acupuncture for neurologic conditions. REVIEW SUMMARY: Acupuncture is a safe procedure when performed by trained professionals. Complications from acupuncture are rare and mainly related to negligence of sterile technique. Studies of the therapeutic value of acupuncture are fraught with challenging methodologic problems, including the choice of a placebo, a suitable control treatment, and the technique of stimulation applied. Clinical trials of the use of acupuncture for pain syndromes (headache, neck, and back pain), stroke rehabilitation, Parkinson's disease, multiple sclerosis, and substance abuse are reviewed. CONCLUSIONS: Based on the current literature, no definitive recommendation can be made regarding the efficacy of acupuncture for common pain syndromes including headache, and neck and back pain. Better quality clinical trials fail to demonstrate efficacy for the use of acupuncture as part of a rehabilitation program following stroke or as a treatment for drug addiction. Acupuncture may have a role in the treatment of sleep disturbance associated with Parkinson's disease but was not efficacious for the primary symptoms of either Parkinson's disease or multiple sclerosis. In light of increasing public interest and use of alternative therapies, this review may be helpful in promoting more discussion between patients and physicians about the use of acupuncture.